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Penetrating Neck Injuries: Mandatory Exploration vs. Nonoperative Management

Penetrating Neck Injuries: Mandatory Exploration vs. Nonoperative Management. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Debate Continues……….

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Penetrating Neck Injuries: Mandatory Exploration vs. Nonoperative Management

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  1. Penetrating Neck Injuries:Mandatory Exploration vs. Nonoperative Management Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. Debate Continues……… “ Some authors have advocated mandatory exploration of all penetrating neck wounds on the basis that serious injury can exist in the absence of clinical findings. Others have advocated a selective approach, operating only upon patients whose finds suggest a major vascular or visceral injury.” A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979, 19:391

  3. Overview – Penetrating Neck Injuries • Management based on “Neck Zones” • Background • Rationale for and against • General clinical diagnosis • Specific injuries – Diagnosis and Management • Carotid • Zone II – Mandatory Exploration vs. Selective Nonoperative • Vertebral • Esophagus • Larynx

  4. History of Neck Zones

  5. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Retrospective study • 189 patients from 1970 -1977 • GSW = 49, SW = 140 • Treatment options • Based on location of neck wound

  6. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Neck zones • Considered level of entrance wound important part of preoperative evaluation • Based on involved vascular structures where distal or proximal control viewed as difficult • Obtained arteriography on all patients with high or low neck wounds • Vascular injury may not obvious • Plan appropriate operative approach to minimize bleeding

  7. Zone III Zone II Zone I Penetrating Neck Zones A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979, 19:391

  8. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Clinical findings • 74 % had one or more signs of vascular, UGI or airway injury • hemorrhage (50%) • hematoma (34%) • shock (15%) • neurologic signs (12%) • 26 % no signs (only 6 % had positive explorations)

  9. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Location of wounds • Middle zone (98 pts) • Low or high zone (91 pts) • Treatments • Middle zone – immediate exploration • Low or high zone – angiogram if stable (62 pts) • negative = 47 • positive = 14 • false positive = 1 • false negative = 0

  10. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Results • 35 patients not explored • 154 patients explored • 47% positive findings • GSW 59% • SW 43% • 123 repairs performed • Venous – 46 • Arterial – 36 • Airway – 26 • Esophageal – 3 • Miscellaneous - 11

  11. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Mortality (2.6 %) • Positive explorations = 2.6 % • Observation = 0% • Negative exploration = 0% • Morbidity (5.3%) • Observation = 0 % • Negative exploration = 4 % • Positive exploration = 7 %

  12. A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979 • Conclusions • All patients with wounds penetrating the platysma should have a neck exploration • Patients with high or low wounds should have preoperative arteriograms if they are stable • Time to exploration • no arteriogram = 2.4 hrs • arteriogram = 4.8 hrs • Angiogram changed approach ( 6 %) • Repair all vascular injuries, unless carotid occluded • Lower mortality with mandatory exploration (?) • Observation = 0 % (required more radiological studies, time, effort, cost) • 2.6 % compared to reported 10-30% with selective observation

  13. Neck Zone Concept Outdated ? • Location of skin wound not a reliable indictor of underlying injuries • Length of neck makes it impractical to divide into three short zones • Wounds often occur at border between zones and difficult to classify

  14. Epidemiology of Penetrating Neck Injuries • 40% do not involve important structures • Types • GSW 50% (direct and indirect damage) • SW 45% • Shotgun 5% • Structures involved • major vein 15-25% • major artery 10-15% • pharynx or esophagus 5-15% • larynx or trachea 4-12% • major nerves 3-8%

  15. Stab vs. Gunshot Wounds • Anecdotal suggestion • explore GSW, non-operative SW • not supported in literature • Prospective study (Demetriades et al, Br J Surg, 1993) • 97 GSW, 89 SW • GSW higher incidence of clinical signs than knives (35% vs. 19%) • GSW more likely injuries • therapeutic operation: GSW 16.5%, SW 10.1%

  16. Clinical Diagnosis – Neck Injuries • Significant injuries often asymptomatic • 25% positive symptoms and 25% positive signs • PE is often deceptively negative for severe injury • Symptoms variable and delayed • internal carotid artery > 2 weeks • esophageal • Weigelt et al, Am J Surg, 1987; 154:619 • 3/10 no signs or symptoms • laryngeal • more likely to have presenting symptoms/signs • voice change, SOB, hemoptysis

  17. Case #1 • 21 yom with GSW to right neck without exit site • c/o pain in throat/right neck • VS : HR 110, BP 130/70, RR 27 sats 98% (40%) • PE: • mild swelling right neck, non-pulsetile • Management options ? • observation (physical exam based) • selective approach • diagnostic approach • mandatory exploration

  18. “Hard” Active or pulsetile bleeding Expanding hematoma Bruit or thrill Neurologic deficit (unilateral) Deficit pulse exam Hypotension “Soft” Nonexpanding hematoma Paresthesias Clinical Signs – Vascular Injury

  19. Physical Exam – Missed Injuries • Fogelman MJ and Stewart RD , Am J Surg,1956, 91:581 • 100 consecutive patients • 43% hemodynamically stable • 70% no sign of bleeding • Carducci et al, Ann Emerg Med, 1985, 15:208 • 1/3 of patients without signs/symptoms • Apffelstaedt et al, World J Surg, 1994, 18:917 • Prospective study, 335 patients • SW penetrating platysma • clinical signs absent 30% of positive neck explorations

  20. Physical Exam - Reliable Diagnosis • Demetriades et al, Br J Surg, 1993 • Prospective, 335 patients, detailed written protocol • 7/335 required angiography • 269/335 non - operatively managed • 2 required subsequent operations for vascular injury • no complications • Demetriades et al, World J Surg, 1996, 21:41 • Prospective, 223 patients, strict written protocol • 160/223 - no clinical signs underwent angiogram • no vascular injury requiring treatment (NPV 100%)

  21. Physical Exam – Reliable Diagnosis • Biffl et al, Am J Surg, 1997, 174:678 • Prospective, 312 patients with penetrating neck injuries • Immediate OR = 105 (symptomatic) • 16 % non-therapeutic • Observation only = 207 (asymptomatic) • 1 delayed operation for esophageal perforation • Sekharan et al, J Vasc Surg, 2000, 32:483 • Prospective, 145 Zone II injuries • Immediate OR = 31 patients (hard signs) • 90% with major arterial/venous injury requiring repair • Observation = 91 patients • Arteriography = 23 patients • 1 required operative repair of common carotid artery

  22. Penetrating Neck Trauma - Radiographic Options • Arteriography • “gold standard” • no or minimal complications • Controversial • Duplex scan • CT angiogram

  23. Angiography • Recommended in Zone I and III • difficult to assess clinically • difficulty surgical exploration • Policy reduces non-therapeutic intervention • Costs (Demetriades et al, Br J Surg, 1993) • Zone I only 5% required operation • Zone III only 13% required operation

  24. Angiography - Zone III GSW

  25. Zone I Injuries - Angiography • Eddy, et al, J Trauma, 2000, 48:208 • ? Mandatory angiography in all Zone I injuries • Retrospective over 10 years, 138 patients • Arteriography vs. Physical exam/CXR • Results • 28 arterial injuries identified • 36 patients had normal PE and CXR • No arterial injuries identified in PE/CXR group

  26. Penetrating Neck Injuries - Duplex • Demetriades et al, Arch Surg, 1995, 130:971 • Prospective, 82 stable patients with neck wounds • Angiography and color flow doppler imaging • Zones: I - 30%, II - 53%, III - 31% • Angiography • Identified 11 lesions, 2 required repair • Doppler • Identified 10 lesions, missed intimal tear in CCA • 91% sensitive, 99 % specific • 100% for clinically important lesions

  27. Penetrating Neck Injuries - Duplex • Ginzberg et al, Arch Surg, 1996, 131:691 • Prospective, 55 stable penetrating neck wounds • Duplex ultrasonography in all patients • Compared results with arteriography or OR findings • Results • Duplex • Normal - 76% • Abnormal – 24% ( 11 truly abnormal, 2 false positive) • Outcomes • NPV 100% • PPV 85%

  28. Penetrating Neck Injuries – CT Angiogram • Gracias et al, Arch Surg, 2001, 136:1231 • Retrospective, 23 stable patients with neck injuries • Helical CT angiogram for trajectory determination • Results • 13/23 had trajectories remote to vital structures • No further intervention • 10/23 underwent angiogram (3 required embolization) • Outcomes • No adverse outcome • Prolonged time to angiogram via CT (added 1.5 hrs) • 4 discharge from ED

  29. Zone II Injuries – CT Angiogram • Mazolewski et al, J Trauma, 2001, 136:1231 • Prospective, 14 stable Zone II injuries • Helical CT angiogram then exploration • Surgeons predicted 4/14 significant injuries by CT scan • Results • 3/14 patients with significant injuries • Correlated with CT findings • Outcomes • Sensitivity 100%, NPV 100%

  30. Management - Mandatory Exploration • Mandatory exploration • Advantages • decreased injuries • up to 25% unexpected injuries found • low morbidity/mortality • Disadvantages • report up 67% negative exploration • Recommendations • Zone II injuries with/without instability • GSW that cross midline

  31. Supportive – Mandatory Exploration • Meyer et al, Arch Surg, 1987, 122:592 • Prospectively studies 120 Zone II injuries • Emergent OR = 7 • Diagnostic evaluation followed by neck exploration = 113 • Arteriography • Barium swallow and flexible esophagoscopy • Laryngoscopy • Outcome accuracy • Clinical assessment = 86 % • Diagnostic assessment = 94 % • Operative assessment = 100 % • Complications = 6%, Mortality = 0.8%

  32. Management - Selective Approach • If hemodynamically stable • angiography, contrast study, endoscopy , laryngoscopy • Exploration if positive study • Negative neck exploration 20% • Disadvantages • cost and time • iatrogenic (CVA, esophageal perforations)

  33. Supportive – Selective Approach • Jurkovich et al, Trauma, 1985, 25:819 • Missed injuries negligible • Sofianos et al, Surgery, 1996, 120:785 • Prospectively studied 75 Zone II injuries • Immediate operation = 40 (hard signs present) • Selective approach = 35 • Only 11 had either arteriography, contrast swallow, or endoscopy • No incidence of missed injury, morbidity, or mortality

  34. Transcervical GSW • More likely to involve vital structures • 73% vs. 31% (GSW not cross midline) • Hirshberg et al, Am J Surg 1994 • retrospective 41 patients • 30(83%) positive for cervical injury • recommends mandatory exploration • Demetriades et al, J of Trauma, 1997 • prospective, 33 patients • 73% injury to vital organ, only 21% therapeutic operation

  35. Treatment Options – Carotid Artery Injuries • Carotid injuries • 22% of penetrating cervical vascular injuries • mortality 10-20% (in-hospital) • Repair vs. ligation • repair if possible in absence of neurologic deficits • prefer saphenous vein, but prosthetics ok • if internal carotid injuries, transposition of external carotid • ligation in neurologically intact for high internal carotid injury if very difficult or impossible

  36. Carotid Artery Injury Management

  37. Carotid Artery Interposition Repair

  38. Carotid Artery Transposition Repair ICA Stump

  39. Treatment Options – Neurologic Deficits • Presence of neurologic deficits • controversial • ? concern of post-vascularization hemorrhagic infarct • increased risk if evidence of severe anemic infarct or edema • recommend repair • if deficits are short of coma • no evidence of anemic infarct • patent distal carotid

  40. Carotid Intimal Flap

  41. Treatment – Intimal Flaps • Minor carotid injuries (intimal flaps) • natural history not known • controversial: observation vs. aggressive approach • ? role of duplex for decision making • role of anti-platelet unproven, but used

  42. Vertebral Artery Pseudoaneurysm

  43. Management – Vertebral Artery Injuries • Vertebral artery • increased frequency secondary liberal angiography • 10% of major vascular injuries • 67% have association with major cervical injury mainly spine • isolate injury asymptomatic in 1/3 patients • thrombosis rarely lead to neurologic sequelae • angiographic embolization standard of care if bleeding

  44. Complications – Vertebral Artery Injuries • Nonoperative Management • delayed bleeding • CVA (dissection, emboli) • pseudoaneurysm • sepsis (missed esophageal leak) • Operative Management • injury to nerves (vagus, hypoglossal, recurrent) • blood loss • missed injury (particularly esophageal)

  45. Summary Treatment - Vascular Injury • Surgical exploration unstable and stable Zone II (board answer) • Angiography Zone I and III • ? Nonoperative management stable Zone II • depends on expertise and facilities • Other interventions • embolization high carotid or vertebral artery • endovascular stent (pseudoaneurysms) • anticoagulation blunt carotid/vertebral artery

  46. Diagnosis – Esophageal Injuries • Blunt esophageal injury rare • High index of suspicion in blunt trauma • Penetrating trauma • evaluation part of a complete work-up • If missed, high morbidity/mortality

  47. GSW Anterior-Posterior Neck

  48. Esophageal Injury - Diagnostic Test • Contrast swallow • Extravasation is diagnostic • Negative study is not reliable (particular in neck with gastrograffin) • 50% of leaks missed with gastrograffin • 25% of leaks missed with barium

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