Farrah Siddiqui, M.D.

Discussion: Francis B. Quinn, Jr., M.D., FACS

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

March 31, 2010

رب زدن عـلما Overview

Background: History of management of PNI

Anatomy & classification of neck zones

Epidemiology

Morbidity & types of injury

Diagnosis

Management

Clinical cases

Conclusions

Background: History 1944: Bailey—early exploration if deep to platysma

1956: Fogelman & Stewart—6% mortality in early exploration vs. 35% if delayed

1979: Roon & Christensen—immediate exploration for middle zone vs. angiogram for stable high or low zones 81% surgery with 53% negative exploration rate

1980s +: Selective management

Clinical Exam

Adjunctive tests: Endoscopy, swallow study

Arteriography

Duplex Ultrasound

Computerized tomography angiography (CTA)

With mandatory exploration, mortality decreased from 15-18% pre WWII to 3-7% during WWII. However, negative exploration increased dramatically—40-60% Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.

Background: History Meyer et al 1987: prospective zone II study, n = 120

5.8% immediate exploration

94.2% had endoscopy & arteriography before surgery

6% morbidity, 0.8% mortality

Biffl WL et al 1997: 18 year prospective study showed selective management of PNI safe

1973-1978: mandatory exploration 56% negative

1978-1996: selective 66% observed

1 missed esophageal injury

16% negative exploration

3 % mortality; 10% morbidity

Biffl WL et al. Selective management of penetrating neck trauma based on cervical level of injury; Denver since 1978

Sniper injury to neck from Spanish Civil War left him with vocal cord paralysis

Anatomy: Zones I - III Zone I: sternal notch

cricothyroid membrane

Zone II: cricothyroid membrane angle of mandible

Zone III: angle of mandible skull base

Is this classification outdated?

Zone I is treated like thoracic injury Anterior neck area classification ant to pos B of SCM; posterior neck not further divided Often patients have multiple wounds or GSW tract can involve multiple zones, so some question importance of this classification Superficial wound does not correspond well to deeper structures injured.

Anatomy: Facial planes

Hematomas, air tracks

Bullet, metal tracks

Carotid space: Carotid, IJV, CN X

Retropharyngeal space: behind pharynx, anterior to prevertebral muscles

Perivertebral space: muscles & soft tissue around vertebrae

www.medscape.com

• Bleeding that displaces prevertebral muscles anteriorly is associated with vertebral body fractures.

• Retropharyngeal carotid artery important for presurgical planning

• Esophageal injury can track air into RP, prevertebral space

• Missed esophageal injuries can present as retropharyngeal abscess, mediastinitis, sepsis

Epidemiology: Adult PNI

1% of all trauma patients in USA

Demetriades et al 1993 GSW more clinical signs & injuries (35% vs. 19% for SW)

Structures injured: 40% no significant damage

Major vein 15-25%

Major artery 10-15%

Digestive tract (pharynx, esophagus) 5-15%

Respiratory tract (larynx, trachea) 4-12%

Major nerves 3-8%

Gun shot (GSW) Stab (SW) Shotgun

45% 40% 4%

• Brywczynski JJ et al. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J 2008; 25: 711-715 metaanalysis of 20 studies

• Demetriades prospective study; 97 GSW, 89 SW

Epidemiology: Pediatric PNI 40% mortality—zones I & III more common

60% zone I—multiple wounds

29% zone II

56% zone III—multiple wounds

Mandatory Neck Exploration Selective Neck Exploration

Hoarseness, aphonia, airway Change in neck exam

Shock, continued bleeding Abnormal diagnostic tests

Blood in aerodigestive tract

Subcutaneous air

Neurologic deficits 86% positive exploration

Multiple major injuries

100% positive exploration

Kim MK et al. Penetrating neck trauma in children: An urban hospital’s experience. Otolayngol Head Neck Surg 2000; 123: 439-43. Upenn n = 35 1990-97 Firearm injuries second leading cause of mortality in age 15-24.

Morbidity: Vascular injury Major Signs

Active bleeding

Unstable/hypotension

Expanding hematoma

Pulsatile swelling

Bruit, thrill

Unilateral CNS deficit

Pulse deficit Minor Signs

Parasthesias

Nonexpanding hematoma

C spine or skull base fractures in MVAs

Morbidity: Vascular injury Carotid artery injury

22% vascular injuries

10-20% mortality in hospital

Repair preferred unless comatose patient

Ligate or embolize if high carotid injury

Minor injury (intimal flap) endovascular repair, ? Anti-platelet Tx

Anticoagulate blunt injury

Vertebral artery injury

10%

2/3 major neck trauma, especially C spine & esophagus

Isolated 1/3 no signs

Sepsis due to missed esophageal injury

Endovascular embolization if bleeding

Ligation low risk

Anticoagulate blunt injury

Morbidity: Esophageal Injury Odynophagia, dysphagia,

hematemesis

Airway injury 25% have esophageal injury

Transcervical trajectory

Saliva in wound, subcutaneous emphysema

Prevertebral air on lateral neck X ray

Kietdumrongwong P & Hemachudha T 2005

Kietdumrongwong P & Hemachudha T. Pneumomediastinum as initial presentation of paralytic rabies: A case reportBMC Infectious Diseases 2005, 5:92.

Morbidity: Esophageal Injury Most commonly missed

Weigelt JA et al 1987: 30% no signs or symptoms

Wood J et al 1989: most common cause delayed morbidity

Asensio JA et al 2001: 34 center study of 405 patients with penetrating esophageal injuries

56% cervical esophagus

19% mortality—most common exsanguination

82% primary repair with 16% requiring muscle flaps

11% drainage

3-4% complex: resection/diversion or resection/anastomosis

41% esophageal complication in delayed repair (vs. 19%)

Empyema, abscess, mediastinitis

Weigelt JA et al. Diagnosis of penetrating cervical esophageal injuries. Am J Surg, 1987; 154 (6): 619-22. Asensio JA et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma-Injury, Infection & Critical Care. 2001; 50(2): 289-96. 34 centers retrospective Wood J et al. Penetrating neck injuries: recommendations for selective management. J Trauma 1989; 29: 602-5.

Morbidity: Esophageal Injury Srinivasan et al 2000: flexible esophagoscopy safe &

accurate Sensitivity = 92.4%, specificity = 100%

PPV = 33.3%, NPV = 100% no injuries missed

Low PPV because incidence of injury low (3.6%)

Imaging Water soluble contrast (gastrograffin): ½ missed

aspiration pneumonitis: not use if poor gag reflex/cough

Barium: ¼ missed

increased mediastinitis

Srinivasan R et al. Role of Flexible Endoscopy in the Evaluation of Possible Esophageal Trauma After Penetrating Injuries. AJG 2000; 95(2): 1725-29. Start with gastrograffin if negative, repeat swallow with barium

Morbidity: Esophagram

Nel L et al 2009

Nel L et al. Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple, cost-effective and accurate. Emerg Med J. 2009;26:106–108

Morbidity: Esophageal Injury Treatment

Observe 24 hrs if high suspicion but studies negative

Pharyngeal injury NPO, IV antibiotics, NGT

Esophageal injury primary repair vs. drainage/ resection/diversion

Early diagnosis primary repair

Late diagnosis with sepsis/inflammation drainage

Morbidity: Airway Injury More common in blunt trauma

5-15% PNI will have laryngotracheal trauma

Hoarseness, stridor, hemoptysis, difficulty breathing, pain

Air leak in wound, difficult airway surgery!!!

Majority airways managed by rapid sequence intubation (RSI) at scene or ED

Mandavia DP 2000 Retrospective N = 748 11% emergent intubation -67% RSI with 100% success -33% fiberoptic 91% success -3 fiberoptic failures RSI

Eggen JT 1993

N = 114 60% intubated, 22% ED No intubation complications

Shearer VE 1993

N = 107 83% RSI with DL 100% success 6% surgical airway 100% 7% awake fiberoptic 98% 4% blind nasotracheal 75%

•Eggen JT et al. Airway management, penetrating neck trauma. J Emerg Med 1993: 11: 31-5. •Mandavia DP et al. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35: 221-5. •Shearer VE et al. Airway management for patients with penetrating neck trauma: a retrospective study. Anasth Analg 1993; 77: 1135-8. •Mandavia et al •Shearer et al

Morbidity: Airway Injury High index of suspicion—avoid paralytic agent!

Trachea most commonly involved (2/3) vs. larynx (1/3)

25% have esophageal injury

Esophageal injury chances of airway injury double

Unstable airway Be prepared for surgical airway

tracheotomy safest option

Stable airway Flexible laryngoscopy, bronchoscopy

CT shows fractures, tracheal injury

OR for endoscopy if suspect injury Steroids, oxygen, IV Abx, humidified air if no fractures, mucosal

disruptions or progressive edema/hematoma

Morbidity: Airway Injury Laryngeal fractures in PNI

Thyroid cartilage most common

Should not delay fixation for > 24 hours since increased risk of scarring

Group Laryngeal Injury Treatment

I Minor endolaryngeal hematoma; No fracture; Good airway

Observe; steroids, PPI, humidity

II Hematoma/edema compromising airway; Laceration without exposed cartilage; Nondisplaced fracture(s)

OR for tracheotomy, DL & esophagoscopy

III Massive edema, exposed cartilage, immobile vocal cord(s), displaced fracture(s)

OR for repair & tracheotomy

IV Group III + more than 2 fracture lines OR for repair & trach

V Laryngotracheal separation OR for repair

Gold SM et al. Blunt laryngeal trauma in children. Arch Otolaryngol Head Neck Surg 1997; 123: 83.

Morbidity: Airway Injury Groups III- V: OR for repair

Repair anterior commissure, TVC lacerations

Cover exposed cartilage

Repair fractures with stainless steel wire or suture

Some prefer absorbable (PDS), others prolene

Nonabsorbable & absorbable miniplates also used

Stent indicated if unstable larynx after fracture fixation or lacerations involving anterior commissure

Remove 10-14 days with endoscopy, remove granulation with CO2 laser

Morbidity: Airway Injury Baisakhiya N et al 2009

Baisakhiya N et al. Laryngotracheal Trauma . The Internet Journal of Otorhinolaryngology. 2009 Volume 9 Number 1 CT shows right thyroid cartilage fracture & air escape suggesting tracheal tear. Extensive subQ air. Patient managed with tracheostomy, reduction of fracture + fixation with 4-0 prolene. Tracheal partially excised with primary repair of trachea.

Morbidity: Airway Injury

Outcomes of penetrating laryngotracheal injury

1/3 delayed diagnosis

10% preventable mortality

Many suffer permanent voice & swallowing problems

Diagnosis: Clinical exam Rivers et al 1988

no vascular injury missed by physical exam

Demetriades et al 1993, n = 335 269 negative exam observed

2 later required intervention for vascular injury

Demetriades et al 1996, n = 223 All patients with negative clinical exam

had arteriogram

No vascular injury requiring intervention

NPV of clinical exam 100%

Biffl et al 1997, n = 312 105 positive exam OR

16% negative exploration

207 negative exam observed

1 esophageal perforation

Sekharan J et al 2000, n = 145 0.7% vascular injury missed

Azuaje R et al 2003 93% sensitive, 97% PPV

Inaba K et al 2006, n = 91 100% sensitive, 93.5% specific

Tisherman SA et al 2008 Clinical exam protocol up to 95% sensitive

injury Demetriades Br J Surg 1993; World J Surg 1996, all prospective Biff et al, Am J Surg 1997, prospective Tisherman SA et al. Clinical practice guideline; penetrating zone II neck trauma. J Trauma 64: 1392-1405, 2008. Inaba K et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the evaluation of penetrating neck trauma. J Trauma 61: 144-149, 2006. n = 91, prospective Azuaje RE et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. The Am Surg. 2003; 69: 804-7. Sekharan J et al. Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: rests of 145 cases. J Vasc Surg 1988; 8: 112-6.

Diagnosis: Clinical Exam Fogelman MJ & Stewart RD 1956: 43% positive explorations were

hemodynamically stable & 70% had no bleeding

Carducci et al 1985: 1/3 patients with positive exploration had no

signs/symptoms on clinical exam

Scalafani et al 1991: 61% sensitivity for vascular injury

Apffelstaedt et al 1994: n = 335 SW; 30% positive explorations had no clinical signs

Eddy VA et al 2000: low sensitivity & NPV with clinical exam but improved in patients when CXR added to physical exam

Fogelman MJ and Stewart RD, Am J Surg 1956, 91: 581. Carducci et al, Ann Emerg Med 1985 15:208 Apffelstaedt World J Surg, 1994, 18: 917 Scalafani SJ et al. The role of angiography in penetrating neck trauma. J Trauma 31: 557-62, 1991. Eddy VA et al. Is routine arteriography mandatory for penetrating injuries to zone I of the neck? J Trauma 2000; 48: 208.

Diagnosis: Arteriography Gold standard for vascular injury

Diagnostic & therapeutic

Zones I & III difficult to assess clinically

Zones I & III often involve complex surgery

Eddy VA et al 2000

N = 138, retrospective review vs. mandatory zone I angio

No arterial injuries on arteriogram if normal exam & CXR

Demetriades et al 1993

Cost-effective for zones I & III

Decreased surgery rates to 5% in zone I & 13% in zone III

Diagnosis: Arteriography Modrall JM et al 1995 meta-analysis: Diagnosis of vascular

trauma

23% positive zones I & III

2.2 to 28% positive zone II only 1% needs surgery

94-100% sensitive

90-98% specific

54-66% PPV high false positive rate

100% NPV no false negatives

0-3% complication, mostly minor

$66,420 per positive arteriogram due to high FP

Modrall JM et al. Diagnosis of vascular trauma. 9(4) 1995.

Diagnosis: Arteriography—arterial injury

Munera F et al 2000

Left carotid artery occlusion seenin angiogram on right as well as parasagittal helical CTA on left

Diagnosis: Arteriography Specialized team

Expensive

0.16-2.0% complication: hematoma, pseudoaneurysm, spasm, thrombosis, emboli, thrombi, arterial dissection

permanent CNS sequelae

Morris C 2008.

Morris C. Vascular and Solid Organ Trauma - Interventional Radiology. www.emedicine.com 2008. Digital subtraction left cervical carotid angiogram demonstrating traumatic injury of the left internal carotid artery, manifested by pseudoaneurysm formation and an intimal dissection

Diagnosis: Arteriography

Endovascular therapy Covered stent graft:

pseudoaneurysm, lacerations, AVF

Embolization or coiling: pseudoaneurysm, AVF

Endovascular occlusion: injured vertebral arteries

Test balloon occlusion prior to ligation

www.medscape.com

Munera F et al 2000 & 2005.

Diagnosis: Arteriography

www.findmeacure.com

Dong Z et al 2006.

Dong Z et al. Endovascular repair for a huge vertebral artery pseudoaneurysm caused by Behcet’s disease. Chinese Medical Journal, 2006, Vol. 119 No. 5 : 435-437

Diagnosis: Duplex U/S Bynoe RP et al 1991, n = 198

95% sensitive, 99% specific

Demetraides D et al 1995 (82) 91% sensitive, 98.6% specific

100% sensitive for clinically significant injuries

Montalvo BM et al 1996 (52) Detected all serious injuries

Limitations Operator dependent

No soft tissue/bony detail

Not useful in zone I & III

•Bynoe RP et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonagraphy. J VAsc Surg 14: 346-52, 1991. prospective •Demetraides D et al. Penetrating injuries of the neck in patients in stable condition: Physical examination, angiography or color flow Doppler imaging. Arch Surg 130: 971-75. 1995. prospective •Montalvo BM et al. Collor Doppler sonography in penetrating injuries of the neck. Am J Neuroradiol. 17: 943-951, 1996. prospective •Picture shows Pseudoaneurysm (arrow) of the femoral artery on angiography and on (B) color duplex ultrasound demonstrating communication and flow between the false aneurysm (FA) and the common femoral artery (CFA) via a neck. (C) Characteristic "to-and-fro" Doppler waveform in the neck of the pseudoaneurysm. (D) Absence of flow within the false aneurysm after successful thrombin injection

Diagnosis: CTA Method:

Nonionic contrast in peripheral IV, care in renal or diabetic

Exam takes 1 min., postprocessing takes 15 min.

Axial usually enough; add multiplanar + 3D for OR plan

Direct signs

Irregular vessel margins, filling defects

Contrast extravasation, lack of vascular enhancement

Vessel caliber changes

Indirect: indistinct perivascular fat plane, bullet/bone fragments within 5 mm of major vessel, hematoma close to vessel

Associated Injuries: C spine, bullet track, aerodigestive

Munera F et al. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. 2005; 58: 413-18. University of Miami, prospective 2 yr. n = 60

Diagnosis: CTA Munera F et al 2000 (2005) (p)

Sensitivity 90% (100%)

Specificity 100% (98.6%)

PPV 100% (92.8%)

NPV 98% (100%)

Inaba K et al 2006 (p)

Sensitivity 100%

Specificity 93.5%

Nondiagnostic 2.2%

Woo K et al 2005 (r)

CTA decreased negative exploration & adjunct tests

Gonzalez RP et al 2003 (p)

Physical exam missed 2 esophageal injuries seen on CTA

Recommend as initial for zone II

Mazolewski PJ et al 2001 (p)

100% sensitive, 91% specific

operative findings in zone II

Gracias VH et al 2001 (r)

Initial test in zones I – III

Decreased overall adjunct studies

MRI/MRA logistics difficult, no bony information

(1st number compared to arteriography; 2nd number compared to actual intervention—surgery or endovascular or observation) Munera F et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology 2000; 216 (2) 356-62. Inaba K et al. Prospective evaluation of screening multislcine helical CTA in the initial evaluation of penetrating neck injuries. J Trauma, Injury, Infection and Critical Care. 2006; 61 (1): 144-56 Gracias VH et al. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg. 2001; 136: 1231-1235. Mazolewski PJ et al. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J Trauma. 2001: 51: 315-19. Gonzalez RP et al. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003; 54: 61-4.

Diagnosis: CTA Woo K et al 2005 Retrospective 1994 – 2004

Patient n = 130

Surgery Negative

Exploration

Angio-graphy

Esopha-gram

CF

Doppler

CTA 34 1

(3%)

0 4

(12%)

4

(12%)

13

(39%)

No CTA 96 32

(33%)

22%

(66%/32)

19

(29%)

17

(26%)

21

(32%)

No CTA 1994-1998: 34% angiogram, 24% esophagram

41% CTA 1999-2004: 11% angiogram, 16% esophagram

Woo Karen et al. CT angiography in penetrating neck trauma reduced the need for operative neck exploration. The American Surgeon 2005.

Diagnosis: Cost-effectiveness of CTA

Seamon MJ et al: extremity CTA versus arteriogram saved $12,922 in patient charges & $1,166 hospital cost

Decreased negative exploration rate cuts OR & patient cost

A Prospective Validation of a Current Practice: The Detection of Extremity Vascular Injury With CT Angiography. Original Article Journal of Trauma-Injury Infection & Critical Care. 67(2):238-244, August 2009. Seamon, Mark J.

Diagnosis: CTA—stab wound

Munera F et al. Multidetector row computed tomography in the management of penetrating neck injuries. Seminals in Ultrasound CT and MRI. 2009. Multiple stab wounds to neck; axial CT (c) shows right skin defect with extension down to jugular vein, no hematoma; B) is maximum intensity projection & A) is color 3D volume rendered image patient taken to OR for debridement & small injury to right IJV repaired

Diagnosis: CTA—arterial injury

Munera F et al 2009.

Self-inflicted GSW to right neck; axial CTA shows large hematoma with contrast extravasation. MIP & 3D show facial artery branching from ECA & running into hematoma,most likely source of bleeding

Diagnosis: CTA—arterial injury

Munera F et al 2005

Right common carotid pseudoaneurysm

Diagnosis: CTA—arterial injury

Munera F et al 2000

Axial CT images from inferior to superior shows progressive narrowing of right ICA; no contrast enhancement seen in superior most (bottom)

Diagnosis: CTA—arterial injury

Munera F et al 2000

Left common carotid pseudoaneurysm with fistula to IJV: left = proximal axial CT, right = at bifurcation; see increased collection of contrast into left IJV as compared to normal right; sagittal recon shows extravasation of contrast and increased enhancement of left IJV

Diagnosis: CTA—venous injury

Munera F et al 2009. Direct injury with thrombosis of right IJV

Diagnosis: CTA—esophageal injury

Munera F et al 2005.

Axial CT shows bullet tract through left neck, close to esophagus; esophagus replaced by large posterior mediastinal hematoma

Diagnosis: CTA—esophageal injury

Rathlev NK et al 2007

Rathlev NK et al. Evaluation and management of neck trauma. Emerg Med Clin N Am 2007; 25: 679-694. Free air adj to esophagus, traumatic perf

Diagnosis: CTA Limitations

1.1 – 2.2% nondiagnostic

Large patients: shoulder obscures neck

Streak artifacts from bullets/metal

Normal variants may look like injuries

Subclavian arteries

Large volume contrast: renal, diabetic patient

Munera F et al 2009.

Munera F et al 2009. GSW to neck, bullet fragments in right carotid space cause streak artifact nondiagnostic CTA required angio which showed dissection

Management Summary Unstable Stable w/ symptoms Stable without

symptoms

Airway injury

Hemodynamic instability

Uncontrolled bleeding

Evolving CVA

Hematoma, hemoptysis, hematemesis, dysphagia, dysphonia, peripheral neuro deficit, subcutaneous air

Mandatory Exploration CTA in all

Selective testing: endoscopy, esophagraphy

Arteriography I & III

Foley tamponade

? Mandatory exploration

Observe > 12 hrs

CTA in all

Arteriography & Esophagraphy in zone I

? exploration

South Africa: Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. Navsaria P et al. World J Surgy 2006 30: 1265-1268

Case 1 24 M, GSW to right neck

Intubated at scene

Vitals currently stable

Right neck swelling, no bruit/thrill

SubQ air

CTA done

What next?

Woo K et al 2005

Woo K et al 2005. CTA allows visualization of bullet tract; carotids are fine; bullet fragments + air in prevertebral + parapharyngeal space esophagram done, no injury noted

Case 2 35 M

Injury to neck with working with axe

chip flew into midline

1 week ago

c/o pain, dysphagia

Vitals stable, no dysphonia

No fever

Wound between thyroid & cricoid, no saliva or air

Gulia J et al 2009

•J. Gulia, S. Yadav, K. Singh & A. Khaowas : Penetrating Neck Injury: Report Of Two Cases. The Internet Journal of Emergency Medicine. 2009 Volume 6 Number 1 •Gulia J et al 2009

Case 3: 40 M, stray shot to neck

c/o pain, some bleeding

Wound anterior neck

No exit wound

No swelling

Mild dysphonia

No airway distress

Vitals stable Sari M et al 2007.

Sari M et al 2007. Atypical penetrating laryngeal trauma. European Journal of Emergency Medicine 2007, 14:230–232

Case 3 Sari M et al 2007.

Flexible laryngoscopy showed airway stable, bilat TVC mobile, right supraglottic edema with bullet lodged OR for DL, bullet removed, no further intervention needed, observed x 24 hrs.

Conclusions Immediate exploration for patients with hard signs

Hemodynamic instability

Uncontrollable bleeding, expanding hematoma

Worsening neurological status

Air bubbling in wound, need for surgical airway

Brywczynski JJ et al 2008: meta-analysis shows C spine injury less common in penetrating trauma

Remove C collar to examine neck !!!

Selective management of stable patients

Conclusions: Selective Management Method Logistics

($, ease)

Reliability Adjunct Tests

Bonus

Physical Exam Cheap

Quick

Large trauma centers

X rays

Esophagram

Endoscopy

No

Duplex Ultrasound

Cheap

Quick

Operator

Zone II only

No

Arteriography Expensive

Time

Specialized

Gold standard vascular injury

Endovascular Treatment

CTA Mid price

Quick

Good

Streak artifacts

Lower rate Bony, tissue, aerodigestiveC spine, bullet tract

Conclusions Zone I Zone II Zone III

CTA CTA CTA

Esophagram/flexible esophagoscopy if suspect/see injury on CT

Flexible laryngoscopy if suspect/see injury on CT

Arteriogram if CTA nondiagnostic, need more information for OR or plan endovascular intervention

OR if injury needs to be surgically assessed/repaired

? Usefulness of whole body CTA in multiple GSW/SW

Neck Zones Obsolete???

Conclusions

Zone I-III classification still works for operative management of vascular injuries

Zone II easy to get proximal & distal control surgery

Zone I & III may try endovascular therapy

Difficult proximal control zone I: median sternotomy

Difficult distal control zone III: skull base

Penetrating neck injury: Algorithm

Munera F et al.

Munera F et al. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. 2005; 58: 413-18. University of Miami, prospective 2 yr. n = 60

Discussion: Francis B. Quinn, Jr., MD Doctor Siddiqui has given an excellent and up‐to‐date summary of the diagnosis and treatment of

penetrating injuries of the neck, with emphasis on the wide range of approaches made possible by

newer imaging techniques. She has pointed out that the earlier "zone" protocol may be soon

overwhelmed by the more modern "selective" management strategies.

The question of evaluating various series of cases is made complicated by the several mechanisms

of injury as drawn from different cultures and environments. We note that 75% of South African

patients present with incised wounds, 50% of U.S. urban patients seek treatment for gunshot

wounds, and our military casualties suffer wounds from low‐velocity shell fragments, as well as high

velocity small caliber rifle bullets, often accompanied by substantial loss of tissue.

Thus, reports of treatment results should allow us to picture the biomechanics of injury, for as has

been shown in a previous Grand Rounds(1,2,3), the high velocity projectile creates instantaneous and

extensive tissue expansion with shearing stress leading to delayed devitalizationand unanticipated

late complications. Further, even low velocity (800 fps) bullets are known to tumble and fragment,

causing tissue injury far from the missile track. In contrast, stabbing or cutting injury causes tissue

injury limited to the track of the weapon.

Doctor Siddiqui's presentation has shown us that the newer treatment methods have laid upon

faculty of resident training institutions the requirement to distill the reports of these methods into a

doctrine suitable for the instruction of those aspiring young surgeons under our direction, a doctrine

which takes into account the local weapons culture as well as the technical and imaging support

available.