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Siletz A, Inaba K. Diagnostic approach to penetrating neck trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:175-182. [PMID: 38523116 DOI: 10.1097/ta.0000000000004292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Anaar Siletz
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (A.S., K.I.), Los Angeles General Medical Center; and Keck School of Medicine (A.S., K.I.), University of Southern California, Los Angeles, California
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2
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Hamilton JM, Chan TG, Moore CE. Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols. Otolaryngol Clin North Am 2023; 56:1013-1025. [PMID: 37353366 DOI: 10.1016/j.otc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.
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Affiliation(s)
- James M Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Tyler G Chan
- Emory University School of Medicine, Atlanta, GA, USA
| | - Charles E Moore
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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3
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Barsoom R, Rendon JJ, Bar-Or D, Palacio CH. Case report: Tree branch penetrating injury into zone III of the neck. Int J Surg Case Rep 2022; 100:107638. [PMID: 36279731 PMCID: PMC9594116 DOI: 10.1016/j.ijscr.2022.107638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Penetrating trauma to the neck can result in severe morbidity and mortality. Location of the injury dictates the appropriate clinical management. Challenging traumatic injuries require resourceful treatment options. CASE PRESENTATION A complex traumatic case of a foreign body penetrating the neck, the parotid gland, disrupting the internal jugular vein, with the tip resting at the anterior aspect of the C1 ring is reported. In this case, the authors seek to describe the clinical management of a vascular injury that resulted from penetrating zone III of the neck. DISCUSSION Due to the complex and dense presence of various structures in the neck, injuries can be difficult to manage. Thus, an algorithm identifies management strategies that are based on the location of the injury, signs of vascular injury, identified injured structures and the hemodynamic stability of the patient. Balloon tamponade has been described in other organs of the body and might be a therapeutic option in patients were venous injuries are difficult to access. CONCLUSION Penetrating neck injuries continue to result in significant morbidity and mortality. However, with appropriate and efficient evaluation and management, better outcomes are expected as demonstrated in this case.
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Affiliation(s)
- Randa Barsoom
- General Surgery Department, Valley Health System, Graduate Medical Education, Las Vegas, NV, United States of America
| | - J. Jesus Rendon
- South Texas Health System – McAllen, 301 West Expressway 83, McAllen, TX 78503, Trauma Department, United States of America
| | - David Bar-Or
- South Texas Health System – McAllen, 301 West Expressway 83, McAllen, TX 78503, Research Department, United States of America
| | - Carlos H. Palacio
- South Texas Health System – McAllen, 301 West Expressway 83, McAllen, TX 78503, Trauma Department, United States of America,Corresponding author.
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4
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Anderson BJ, Allen DZ, McKee SP, Low G, Yuksel S. Traumatic xylophagia leading to foreign body removal and tracheostomy in the setting of postpartum psychosis. J Surg Case Rep 2021; 2021:rjab467. [PMID: 34909161 PMCID: PMC8666155 DOI: 10.1093/jscr/rjab467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/26/2021] [Indexed: 11/23/2022] Open
Abstract
Postpartum psychosis (PPP) is a severe mood disorder following childbirth that rarely leads to injurious or suicidal behavior. This report illustrates otolaryngologic intervention for pharyngeal laceration and airway instability following traumatic foreign body ingestion in the setting of PPP. A 25-year-old woman with PPP presented with hemoptysis after attempting suicide by traumatically forcing tree branches into her oropharynx. Imaging revealed pneumomediastinum, and flexible laryngoscopy and esophagoscopy showed a large foreign body (tree branch) extending from the hypopharynx to the gastroesophageal junction. She was taken to the operating room for direct microlaryngoscopy, bronchoscopy and esophagoscopy with removal of the 25-cm tree branch. Panendoscopy revealed a mucosal laceration at the cricopharyngeus with supraglottic and hypopharyngeal edema but no injury to the larynx. Due to airway concerns, a cuffed tracheostomy was placed along with a gastrostomy tube for feeding access. She tolerated her postoperative course with successful decannulation and oral feeding prior to discharge.
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Affiliation(s)
- Brady J Anderson
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - David Z Allen
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Sean P McKee
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Garren Low
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Sancak Yuksel
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
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Nyberg SM, Vasquez DG, Brown EM, Ntelekos J, Stanley MR, Williams MA. Traumatic Hypopharyngeal Perforation from Football Helmet Chinstrap. Kans J Med 2021; 14:231-233. [PMID: 34540139 PMCID: PMC8415386 DOI: 10.17161/kjm.vol1415290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/05/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- Sue M Nyberg
- Department of Physician Assistant, Wichita State University, Wichita, KS
| | - Donald G Vasquez
- Department of Trauma Services, Wesley Medical Center, Wichita, KS.,Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Eric M Brown
- Department of Physician Assistant, Wichita State University, Wichita, KS
| | - Jimmy Ntelekos
- Department of Physician Assistant, Wichita State University, Wichita, KS
| | - Marcella R Stanley
- Department of Physician Assistant, Wichita State University, Wichita, KS
| | - Matthew A Williams
- Department of Physician Assistant, Wichita State University, Wichita, KS
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6
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Das S, Lakshmanan J, Alexander A, Hansdah R. Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm. BMJ Case Rep 2021; 14:e244098. [PMID: 34493559 PMCID: PMC8424826 DOI: 10.1136/bcr-2021-244098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/04/2022] Open
Abstract
External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.
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Affiliation(s)
- Sauradeep Das
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Jijitha Lakshmanan
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Arun Alexander
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Rashmi Hansdah
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
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Honda M, Tanioka T, Haruki S, Kamata Y, Hoshi H, Ryu K, Yagi K, Ueno K, Matsui S, Ohata Y, Hasegawa F, Kaito A, Arita K, Ito K, Takiguchi N. Thoracic esophageal injury due to a neck stab wound: a case report. Surg Case Rep 2021; 7:126. [PMID: 34014419 PMCID: PMC8137774 DOI: 10.1186/s40792-021-01208-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade. CASE PRESENTATION A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries. CONCLUSIONS The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.
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Affiliation(s)
- Masaki Honda
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Toshiro Tanioka
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan.
| | - Shigeo Haruki
- Department of Esophageal Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Hokomagome, Bunkyo, Tokyo, Japan
| | - Yuko Kamata
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Hiromasa Hoshi
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Kyoko Ryu
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Kenta Yagi
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Kodai Ueno
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Satoshi Matsui
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Yoshiteru Ohata
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Fumi Hasegawa
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Akio Kaito
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Kaida Arita
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Koji Ito
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
| | - Noriaki Takiguchi
- Department of Digestive Surgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otuno, Tsuchiura-shi, Ibaraki, Japan
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8
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Herrera MA, Tintinago LF, Victoria Morales W, Ordoñez CA, Parra MW, Betancourt-Cajiao M, Caicedo Y, Guzmán-Rodríguez M, Gallego LM, González Hadad A, Pino LF, Serna JJ, García A, Serna C, Hernández-Medina F. Damage control of laryngotracheal trauma: the golden day. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4124599. [PMID: 33795902 PMCID: PMC7968428 DOI: 10.25100/cm.v51i4.4422.4599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Laryngotracheal trauma is rare but potentially life-threatening as it implies a high risk of compromising airway patency. A consensus on damage control management for laryngotracheal trauma is presented in this article. Tracheal injuries require a primary repair. In the setting of massive destruction, the airway patency must be assured, local hemostasis and control measures should be performed, and definitive management must be deferred. On the other hand, management of laryngeal trauma should be conservative, primary repair should be chosen only if minimal disruption, otherwise, management should be delayed. Definitive management must be carried out, if possible, in the first 24 hours by a multidisciplinary team conformed by trauma and emergency surgery, head and neck surgery, otorhinolaryngology, and chest surgery. Conservative management is proposed as the damage control strategy in laryngotracheal trauma.
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Affiliation(s)
- Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Tintinago
- Fundación Valle del Lili, Department of Surgery, Division of Head and Neck Surgery, Cali, Colombia
| | - William Victoria Morales
- Fundación Valle del Lili, Department of Surgery, Division of Head and Neck Surgery, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | | | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | | | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Carlos Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fabian Hernández-Medina
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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9
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Saravanam PK, Arunachalam R. Management of Post-Traumatic Subglottic Stenosis and Pharyngosubglottic Fistula. Indian J Otolaryngol Head Neck Surg 2019; 71:537-541. [PMID: 31742017 DOI: 10.1007/s12070-018-1390-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/02/2018] [Indexed: 11/25/2022] Open
Abstract
Injury to the aerodigestive tract following external laryngeal trauma is rare. Reports of acquired laryngopharyngeal fistula are very few. We report a very rare presentation of penetrating neck trauma presenting with fracture of the cricoid cartilage, subglottic stenosis and pharyngosubglottic fistula. The term 'pharyngosubglottic fistula' is used here for the first time to describe a communication tract between hypopharynx and subglottis. The successful surgical management of this case is discussed.
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Affiliation(s)
- Prasanna Kumar Saravanam
- Department of ENT, Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, 600038 India
| | - Ravikumar Arunachalam
- Department of ENT, Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, 600038 India
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10
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Go JL, Acharya J, Branchcomb JC, Rajamohan AG. Traumatic Neck and Skull Base Injuries. Radiographics 2019; 39:1796-1807. [PMID: 31589581 DOI: 10.1148/rg.2019190177] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with blunt and penetrating traumatic injuries to the skull base and soft tissues of the neck present to the emergency department every day. Fortunately, truly life-threatening injuries to these regions are relatively uncommon. However, when encountered and not correctly diagnosed, these entities may result in severe morbidity or mortality. The radiologist plays a critical role recognizing these injuries, in which findings may often be subtle and the anatomy potentially challenging to identify. Multisection CT and CT angiography are commonly performed to assess these injuries in the emergency department. Vascular injury to the neck may result in dissection, occlusion, pseudoaneurysm formation, or frank extravasation resulting in stroke or death. Airway compromise may result from laryngotracheal injury. Injuries to the pharynx and esophagus may result in perforation. Injuries to the temporal bone may result in vascular injury to the internal carotid artery or facial nerve injury, which would require immediate surgery or intervention to prevent paralysis.©RSNA, 2019.
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Affiliation(s)
- John L Go
- From the Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif, and LAC+USC Medical Center, 1983 Marengo Street, D and T Tower, Room 3D321, Los Angeles, CA 90033
| | - Jay Acharya
- From the Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif, and LAC+USC Medical Center, 1983 Marengo Street, D and T Tower, Room 3D321, Los Angeles, CA 90033
| | - Jasmine C Branchcomb
- From the Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif, and LAC+USC Medical Center, 1983 Marengo Street, D and T Tower, Room 3D321, Los Angeles, CA 90033
| | - Anandh G Rajamohan
- From the Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif, and LAC+USC Medical Center, 1983 Marengo Street, D and T Tower, Room 3D321, Los Angeles, CA 90033
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11
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Xiang G, Wu Z, Zhao X, Zhao X, Feng Y. Nail Gun Injury of the Spine: Case Report and Review of the Literature. World Neurosurg 2019; 132:321-325. [PMID: 31470149 DOI: 10.1016/j.wneu.2019.08.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the first report about nail gun injuries in 1959, there has been an average of approximately 37,000 patients hurt by nail guns and treated in emergency departments. Carotid arterial injury by nail gun has been reported, but vertebral artery damage is extremely rare. CASE DESCRIPTION A 42-year-old man was transported to the emergency department after suffering an accidental self-inflicted nail gun injury to the left lateral aspect of his neck. Radiographic imaging of the cervical spine revealed a 3.1-cm metallic nail in the C5 region. A computed tomography (CT) angiogram revealed the nail passing through the left C5 transverse foramen and compressing the left vertebral artery. He was immediately brought to the operating room for removal of the nail. At 1-month follow-up, the patient did not have any neck complaints and postoperative CT angiogram indicated the patient was asymptomatic with no signs of complication or infection. CONCLUSIONS Based on our experience and a review of the literature, in terms of treating a nail gun injury to the cervical spine, we would like emphasize that preoperative CT scan or CT angiogram is necessary to assess the location and shape of the nail, especially nails with barbers or washers. Improving awareness of the risk from accidental nail gun trauma may lead to better prevention of this rare but potentially life-threatening injury.
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Affiliation(s)
- Geng Xiang
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China
| | - Zixiang Wu
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China
| | - Xiong Zhao
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China
| | - Xiaolei Zhao
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China
| | - Yafei Feng
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China.
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12
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Penetrating neck trauma: radiological predictors of vascular injury. Eur Arch Otorhinolaryngol 2019; 276:2541-2547. [PMID: 31218447 DOI: 10.1007/s00405-019-05517-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Vascular injury in penetrating neck trauma predicts a poorer outcome and usually requires surgical neck exploration. Multi-detector computed tomography (MDCT) angiography is a readily available non-invasive diagnostic tool that can identify direct and indirect signs of vascular injury in stable patients. This study aims to investigate the diagnostic accuracy of radiological signs of vascular injury on MDCT, and their implications on patient management in the setting of penetrating neck trauma. METHODS A retrospective cohort study of penetrating neck injuries (PNI) between 2012 and 2018 in a UK major trauma centre was performed. Clinical data and operative findings were compared with radiological findings on MDCT performed at the time of admission. RESULTS 157 patients were identified with PNI in the study period, with 67 meeting inclusion criteria. The predictive value of indirect radiological signs of vascular injury alone was low, with only 12.1% of these patients having significant vascular injury found at neck exploration. However, the combined use of direct radiological signs with clinical signs resulted in a specificity of 97.7% for vascular injury. CONCLUSIONS The use of direct and indirect radiological signs of vascular injury can increase the accuracy of diagnosis when used in conjunction with clinical signs. Combining clinical assessment and radiological investigation, specifically contrast-enhanced MDCT, improves the specificity in pre-operative assessment of potential vascular injury in PNI. MDCT is recommended in stable patients with clinical signs of vascular injury to reduce the rate of negative neck exploration.
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13
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Abstract
The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.
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14
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Tatum JM, Barmparas G, Dhillon NK, Edu S, Margulies DR, Ley EJ, Nicol AJ, Navsaria PH. Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011. J INVEST SURG 2019; 33:896-903. [PMID: 30897974 DOI: 10.1080/08941939.2019.1576810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.
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Affiliation(s)
- James M Tatum
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sorin Edu
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew J Nicol
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Pradeep H Navsaria
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Blunt Pharyngoesophageal Injury: an Overview of a Rare Entity. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0162-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth 2018; 117 Suppl 1:i49-i59. [PMID: 27566791 DOI: 10.1093/bja/aew193] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. METHODS A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763). RESULTS A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns. CONCLUSIONS The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.
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Affiliation(s)
- S J Mercer
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Defence Medical Services, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK Postgraduate School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, UK
| | - C P Jones
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - M Bridge
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - E Clitheroe
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - B Morton
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Honorary Research Fellow, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - P Groom
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
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Barmparas G, Navsaria PH, Serna-Gallegos D, Nicol AJ, Edu S, Sayari AA, Margulies DR, Ley EJ. Blunt Pharyngoesophageal Injuries: Current Management Strategies. Scand J Surg 2018; 107:336-344. [PMID: 29628012 DOI: 10.1177/1457496918766692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. METHODS: The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. RESULTS: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03). CONCLUSION: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.
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Affiliation(s)
- G Barmparas
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - P H Navsaria
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D Serna-Gallegos
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A J Nicol
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - S Edu
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - A A Sayari
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D R Margulies
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - E J Ley
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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"No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res 2017; 221:113-120. [PMID: 29229116 DOI: 10.1016/j.jss.2017.08.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/04/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a "no zone" approach. METHODS An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries). RESULTS A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs (P = 0.23) or soft signs (P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE. CONCLUSIONS Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking.
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Herb B, Meltzer J, Lim CA. Dysphagia in a Teenager With Neck Trauma. Clin Pediatr (Phila) 2017; 56:301-304. [PMID: 27107007 DOI: 10.1177/0009922816645523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Brandon Herb
- 1 Albert Einstein College of Medicine, Bronx, NY, USA
| | - James Meltzer
- 1 Albert Einstein College of Medicine, Bronx, NY, USA.,2 Jacobi Medical Center, Bronx, NY, USA
| | - C Anthoney Lim
- 1 Albert Einstein College of Medicine, Bronx, NY, USA.,2 Jacobi Medical Center, Bronx, NY, USA
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20
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Nonfatal Cervical-Neck Lesion With a Wooden Foreign Body: Diagnosis and Management. J Craniofac Surg 2016; 27:175-6. [PMID: 26674918 DOI: 10.1097/scs.0000000000002338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Penetrating cervical lesions caused by a foreign body are rare events. The neck is a complex and delicate body region, given the important vascular structures it holds. The most frequent fatal complications often involve vascular injuries, and as a consequence, the mortality rate increases by approximately 50%. Civilian patients are mainly victims of violence or motor vehicle accidents and rural accidents involving neck are not very common. When a cervical lesion is because of a wooden foreign body, infectious risk increases for its organic peculiarity. The authors report a rural nonfatal cervical lesion in a civilian, and its management.
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Conradie WJ, Gebremariam FA. Can computed tomography esophagography reliably diagnose traumatic penetrating upper digestive tract injuries? Clin Imaging 2015; 39:1039-45. [DOI: 10.1016/j.clinimag.2015.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 07/08/2015] [Accepted: 07/10/2015] [Indexed: 12/26/2022]
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Bodanapally UK, Shanmuganathan K, Dreizin D, Stein D, Reddy AK, Mirvis SE, Vasquez M, Cardarelli C, Guardiani E. Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm. Eur Radiol 2015; 26:2409-17. [DOI: 10.1007/s00330-015-4050-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 07/15/2015] [Accepted: 09/28/2015] [Indexed: 11/29/2022]
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Reginelli A, Russo A, Maresca D, Martiniello C, Cappabianca S, Brunese L. Imaging assessment of gunshot wounds. Semin Ultrasound CT MR 2014; 36:57-67. [PMID: 25639178 DOI: 10.1053/j.sult.2014.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm. Wounds are generally classified as low velocity (less than 609.6m/s) or high velocity (more than 609.6m/s). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they are slow and cause more tissue damage, but this is only a very approximate guide. However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as the kinetic energy, stability, entrance profile and path traveled through the body, and the biological characteristics of the tissues injured. Hemodynamically stable patients and patients who stabilized after simple immediate resuscitation were evaluated with a careful history and physical examination. A routine x-ray is performed in patients with gunshot wounds. Indication for total body computed tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical care are not diagnosed, or hemostasis may be preliminary reached in the emergency room. Hemodynamically stable patients with no history and clinical examination showing suspected vascular damage are allowed in the radiology department for obtaining a total body CT scan with intravenous contrast medium and then transferred to the surgical ward trauma for observation. After 24 hours without the complications, patient can be discharged. CT is the procedure of choice to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, musculoskeletal lesions, and vessels injuries and is useful for assessing medicolegal aspects as trajectory and the anatomical structures at risk.
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Affiliation(s)
- Alfonso Reginelli
- Department of Internal and Experimental Medicine, Magrassi-Lanzara, Second University of Naples, Naples, Italy.
| | - Anna Russo
- Department of Radiology, S. G. Moscati Hospital, Aversa, Italy
| | - Duilia Maresca
- Department of Internal and Experimental Medicine, Magrassi-Lanzara, Second University of Naples, Naples, Italy
| | | | - Salvatore Cappabianca
- Department of Internal and Experimental Medicine, Magrassi-Lanzara, Second University of Naples, Naples, Italy
| | - Luca Brunese
- Department of Internal and Experimental Medicine, Magrassi-Lanzara, Second University of Naples, Naples, Italy; Department of Health Science, University of Molise, Campobasso, Italy
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Prokakis C, Koletsis EN, Dedeilias P, Fligou F, Filos K, Dougenis D. Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg 2014; 9:117. [PMID: 24980209 PMCID: PMC4104740 DOI: 10.1186/1749-8090-9-117] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 06/23/2014] [Indexed: 12/17/2022] Open
Abstract
Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.
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Affiliation(s)
- Christos Prokakis
- Department of Cardiothoracic Surgery, University of Patras, School of Medicine, Patras, Greece
| | - Efstratios N Koletsis
- Department of Cardiothoracic Surgery, University of Patras, School of Medicine, Patras, Greece
| | | | - Fotini Fligou
- Department of Anesthesiology and Intensive Care, University of Patras, School of Medicine, Patras, Greece
| | - Kriton Filos
- Department of Anesthesiology and Intensive Care, University of Patras, School of Medicine, Patras, Greece
| | - Dimitrios Dougenis
- Department of Cardiothoracic Surgery, University of Patras, School of Medicine, Patras, Greece
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Kaya KH, Koç AK, Uzut M, Altintaş A, Yeğin Y, Sayın I, Kayhan FT. Timely management of penetrating neck trauma: Report of three cases. J Emerg Trauma Shock 2013; 6:289-92. [PMID: 24339665 PMCID: PMC3841539 DOI: 10.4103/0974-2700.120382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 03/06/2013] [Indexed: 11/04/2022] Open
Abstract
In head and neck surgery, penetrating neck injuries are uncommon. The neck contains many important structures, so such trauma can cause significant morbidity and mortality. A patient with penetrating neck trauma should be examined promptly in the emergency room. If possible, damaged tissue and organ fragments should be preserved carefully.
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Affiliation(s)
- Kamil Hakan Kaya
- Department of Otorhinolaryngology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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26
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Schaefer SD. Management of acute blunt and penetrating external laryngeal trauma. Laryngoscope 2013; 124:233-44. [PMID: 23804493 DOI: 10.1002/lary.24068] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/22/2013] [Accepted: 01/31/2013] [Indexed: 01/27/2023]
Abstract
OBJECTIVES/HYPOTHESIS Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. DATA SOURCE Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. REVIEW METHODS Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. RESULTS Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. CONCLUSIONS Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function.
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Affiliation(s)
- Steven D Schaefer
- New York Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Lenox Hill Hospital of the North Shore Long Island Jewish Health System and New York Medical College, New York, New York, U.S.A
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Sung EK, Nadgir RN, Sakai O. Computed tomographic imaging in head and neck trauma: what the radiologist needs to know. Semin Roentgenol 2013; 47:320-9. [PMID: 22929691 DOI: 10.1053/j.ro.2012.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Edward K Sung
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
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Cho J, Park MR, Kim J, Jeong HS, Ahn K. Pyriform Sinus Perforation in a Child after Falling with a Spoon Handle in the Mouth. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.3.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi-Ran Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihyun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han-Sin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kangmo Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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29
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Soliman AMS, Ahmad SM, Roy D. The role of aerodigestive tract endoscopy in penetrating neck trauma. Laryngoscope 2012; 124 Suppl 7:S1-9. [PMID: 23070927 DOI: 10.1002/lary.23611] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE/HYPOTHESIS To determine the role of aerodigestive tract endoscopy in the management of penetrating neck trauma. STUDY DESIGN Retrospective case series. METHODS A search of the hospital's trauma database was performed for patients who presented with penetrating neck trauma between July 1989 and June 2008. The mechanism and site of injury, airway status and manipulation, physical findings, diagnostic and therapeutic steps taken, and outcomes were all recorded. RESULTS One hundred sixty-three patients were identified. There were 144 males and 19 females. The mean age was 28 years (range, 13 to 65 years). There were 105 gunshot wounds, 9 shotgun injuries, and 48 stab wounds. Seventy-three patients (45%) underwent emergent neck exploration, of which 15 had upper aerodigestive tract injuries; intraoperative endoscopy was performed on 13 and was used to guide the repair. Ninety patients (55%) did not meet the criteria for emergent neck exploration. Endoscopy in this group was performed in symptomatic patients, which revealed two cases of unilateral true vocal fold motion impairment, one mucosal laceration of the right mainstem bronchus, one questionable area of injury at the apical segment of the right upper lobe bronchus, and one mucosal laceration of the proximal esophagus. CONCLUSIONS Aerodigestive tract endoscopy is critical in assessing and guiding surgical repair of injuries noted on surgical exploration. In stable patients with a low clinical suspicion of aerodigestive tract injury, it was of low yield. We propose a new algorithm for assessing aerodigestive tract injuries that includes multidetector computed tomography, in which only symptomatic patients who fail to meet the criteria for emergent neck exploration undergo endoscopy. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Ahmed M S Soliman
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, U.S.A
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Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging 2012; 3:419-31. [PMID: 22945428 PMCID: PMC3443277 DOI: 10.1007/s13244-012-0191-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 08/05/2012] [Accepted: 08/08/2012] [Indexed: 11/28/2022] Open
Abstract
Background Penetrating trauma of the neck and face is a frequent presentation to acute emergency, trauma and critical care units. There remains a steady incidence of both gunshot penetrating injury to the neck and face as well as non-missile penetrating injury—largely, but not solely, knife-related. Optimal imaging assessment of such injuries therefore remains an on-going requirement of the general and specialised radiologist. Methods The anatomy of the neck and face—in particular, vascular, pharyngo-oesophageal, laryngo-tracheal and neural anatomy—demands a more specialised and selective management plan which incorporates specific imaging techniques. Results The current treatment protocol of injuries of the neck and face has seen a radical shift away from expectant surgical exploration in the management of such injuries, largely as a result of advances in the diagnostic capabilities of multi-detector computed tomography angiography (MDCTA), which is now the first-line imaging modality of choice in such cases. Conclusion This review aims to highlight ballistic considerations, differing imaging modalities, including MDCTA, that might be utilised to assist in the accurate assessment of these injuries as well as the specific radiological features and patterns of specific organ-system injuries that should be considered and communicated to surgical and critical care teams. Teaching points • MDCTA is the first-line imaging modality in penetrating trauma of the neck and, often, of the face • The inherent deformability of a bullet is a significant factor in its tissue-damaging capabilities • MDCTA can provide accurate assessment of visceral injury of the neck as well as vascular injury • Penetrating facial trauma warrants radiological assessment of key adjacent anatomical structures • In-driven fragments of native bone potentiate tissue damage in projectile penetrating facial trauma
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Affiliation(s)
- Curtis Offiah
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, E1 1BB, UK,
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Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg 2012; 72:576-83; discussion 583-4; quiz 803-4. [PMID: 22491539 DOI: 10.1097/ta.0b013e31824badf7] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this prospective multicenter study was to evaluate a clinical protocol integrating multidetector computed tomographic angiography (MDCTA) as the initial screening examination for the work-up of penetrating neck injury. METHODS All penetrating neck injuries assessed at two Level I trauma centers (January 2009-July 2011) prospectively underwent a structured clinical examination. Those with hard signs of injury (active bleed, instability, expanding/pulsatile hematoma, bruit/thrill, hemoptysis, hematemesis, and air bubbling) underwent exploration, those who were asymptomatic were observed. The remainder, with soft signs underwent MDCTA. Sensitivity and specificity were tested against an aggregate gold standard of operative intervention, clinical follow-up, and when obtained, conventional angiography, bronchoscopy, esophagogram, and esophagoscopy. RESULTS Four hundred fifty-three penetrating neck injuries were evaluated. Hard signs of vascular or aerodigestive tract injury were observed in 8.6% with an 89.7% incidence of clinically significant injury. 41.7% had no signs of injury and were observed with no missed injuries (follow-up, 2.6 days ± 1.1 days [1-58 days]). The remaining 225 (49.7%) underwent MDCTA (stab wound, 61.3%; gunshot wound, 37.8%; shotgun, 0.9%). The external wounds were in zone II (38.2%), multiple (28.9%), zone I (16.9%), and zone III (16.0%). Twenty-eight injuries were found in 22 patients (5 internal jugular-V, 2 external jugular-V, 1 vertebral-A, 7 common carotid-A, 2 internal carotid-A, 3 external carotid-A, 2 subclavian-A, 3 esophagus, and 3 tracheas). Five patients had false-positive findings (2 vascular and 3 aerodigestive tract). The 194 negative studies (follow-up, 5.5 days ± 7.5 days [1-27 days]) had no delayed diagnosis of injury. MDCTA was nondiagnostic in four patients (1.8%), secondary to artifact. One of these had a vertebral-A injury diagnosed at angiography. MDCTA achieved 100% sensitivity and 97.5% specificity in detecting all clinically significant injuries. CONCLUSION In the initial evaluation of patients who have sustained penetrating neck trauma, physical examination can safely reduce unnecessary imaging. If imaging is required, MDCTA is a highly sensitive and specific screening modality for evaluating the vascular and aerodigestive structures in the neck. LEVEL OF EVIDENCE II, prospective study.
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Brennan J, Lopez M, Gibbons MD, Hayes D, Faulkner J, Dorlac WC, Barton C. Penetrating Neck Trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2010; 144:180-5. [DOI: 10.1177/0194599810391628] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting. Study Design. Case series with chart review. Setting. Air Force Theater Hospital at Balad Air Base, Iraq. Subjects and Methods. The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended. Results. One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%. Conclusions. The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.
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Affiliation(s)
- Joseph Brennan
- Wilford Hall Medical Center, Lackland Air Force Base, TX, USA
| | - Manuel Lopez
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | - David Hayes
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | | | - Chester Barton
- United States Air Force Academy Hospital, Colorado Springs, CO, USA
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Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging Evaluation of Penetrating Neck Injuries. Radiographics 2010; 30:869-86. [DOI: 10.1148/rg.304105022] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Casey SJ, De Alwis WD. Review article: Emergency department assessment and management of stab wounds to the neck. Emerg Med Australas 2010; 22:201-10. [DOI: 10.1111/j.1742-6723.2010.01285.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nail Gun Injury to the Craniocervical Junction: A Case Report and Review of the Literature. ACTA ACUST UNITED AC 2010; 68:E99-103. [DOI: 10.1097/ta.0b013e318169cd5f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Life-threatening complications due to apparently minor penetrating neck injuries can occur. We present the case of a 16-year-old boy, who had what initially appeared to be a superficial stab wound to his neck. After further evaluation, he was found to have major injuries to his larynx and esophagus. This case underscores the importance of a careful evaluation after any penetrating neck injury, even one that initially appears to be trivial. The pertinent literature regarding penetrating neck trauma is reviewed.
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Kesser BW, Chance E, Kleiner D, Young JS. Article Commentary: Contemporary Management of Penetrating Neck Trauma. Am Surg 2009. [DOI: 10.1177/000313480907500101] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bradley W. Kesser
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Elizabeth Chance
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Daniel Kleiner
- Department of General Surgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Jeffrey S. Young
- Department of General Surgery, University of Virginia Medical Center, Charlottesville, Virginia
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Abstract
Penetrating face and neck trauma is usually obvious, but blunt trauma mandates high index of suspicion to recognize its existence. Comprehensive understanding of the injury is mandatory to plan the best timing and method to secure the airway.
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Affiliation(s)
- Edgar J Pierre
- Department of Anesthesiology Perioperative Medicine and Pain Management, Ryder Trauma Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
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Inaba K, Munera F, McKenney M, Rivas L, de Moya M, Bahouth H, Cohn S. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. ACTA ACUST UNITED AC 2006; 61:144-9. [PMID: 16832262 DOI: 10.1097/01.ta.0000222711.01410.bc] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck. METHODS After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained. RESULTS In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA. CONCLUSION In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted.
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Affiliation(s)
- Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, California 90033, USA.
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Luqman Z, Khan MAM, Nazir Z. Penetrating pharyngeal injuries in children: trivial trauma leading to devastating complications. Pediatr Surg Int 2005; 21:432-5. [PMID: 15891890 DOI: 10.1007/s00383-005-1447-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2005] [Indexed: 11/25/2022]
Abstract
Pharyngeal perforations are uncommon in children and are usually secondary to instrumentation or external penetrating injuries. A delay in management can lead to life-threatening complications such as retropharyngeal abscess, mediastinitis, and airway compromise. We report three children who had pharyngeal perforation due to apparently innocuous injury and who developed serious complications. A high index of suspicion for a significant pharyngeal injury, use of lateral soft-tissue x-ray films of the neck, and flexible endoscopy in the emergency room can assist in early diagnosis when evaluating patients with oropharyngeal and penetrating neck injury. Prompt administration of broad-spectrum antibiotics, local drainage, and debridement can avert life-threatening complications.
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Affiliation(s)
- Zubair Luqman
- Department of Surgery, The Aga Khan University Hospital, P.O. Box 3500, Stadium Road, Karachi, Pakistan
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Smakman N, Nicol AJ, Walther G, Brooks A, Navsaria PH, Zellweger R. Factors affecting outcome in penetrating oesophageal trauma. Br J Surg 2004; 91:1513-9. [PMID: 15386317 DOI: 10.1002/bjs.4760] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Penetrating oesophageal trauma is rare and the risk factors affecting outcome have not been clearly identified. Delayed management has been cited as a factor contributing to the high rates of morbidity and mortality, but evidence for this is lacking.
Methods
A retrospective study was undertaken of patients with penetrating oesophageal trauma presenting to a level I trauma centre over 8 years. Outcome was assessed in terms of mortality, morbidity (oesophageal and non-oesophageal), and length of hospital and intensive care unit (ICU) stays.
Results
Fifty-two patients with oesophageal injury who reached the operating theatre were included. The overall mortality rate was 6 per cent. Fifteen patients (29 per cent) developed oesophageal injury-related complications. Time from injury to management was the only important risk factor for the development of oesophageal complications (P = 0·001), but did not affect the length of ICU (P = 0·560) or hospital (P = 0·329) stay, incidence of non-oesophageal injury-related complications (P = 0·963) or death (P = 0·937). Patients with gunshot injuries spent longer in the ICU (P = 0·007) and the duration of hospital stay was longer for those with higher-grade oesophageal injuries (P = 0·025).
Conclusion
The risk of oesophageal injury-related complications was directly related to the interval between the trauma and definitive management of the oesophageal injury.
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Affiliation(s)
- N Smakman
- Department of Surgery, Trauma Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Abstract
Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.
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Affiliation(s)
- Bryan A Cotton
- From the Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Bowley DM, Robertson SJ, Boffard KD, Bhagwanjee S. Resuscitation and anaesthesia for penetrating trauma. Curr Opin Anaesthesiol 2003; 16:165-71. [PMID: 17021456 DOI: 10.1097/00001503-200304000-00010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW The worldwide burden of trauma is increasing, but is unequal between nations. Trauma targets the young and productive in society and imposes a major burden on the health infrastructure. This review provides a distillation of practice in a busy urban trauma centre dealing with large volumes of penetrating trauma. RECENT FINDINGS The anaesthetist holds a pivotal role in the management of penetrating injury; the requirements of prompt airway control, early delivery to theatre and control of a physiologically brittle patient can be challenging. Recognition that attempts at definitive surgery in exsanguinating patients may do more harm than good has made surgery a tool of resuscitation rather than an end in itself. SUMMARY Depending on where they practice, clinicians are more or less likely to encounter patients with gunshot wounds. However, adherence to basic principles and attention to the details of temperature control, invasive haemodynamic monitoring, blood product therapy and effective communication should translate to improved outcomes for patients after penetrating trauma.
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Affiliation(s)
- Douglas M Bowley
- University of the Witwatersrand Medical School, Johannesburg, Republic of South Africa
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