Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem

Abstract

WHAT THIS PAPER ADDS This evidence driven clinical scenario summarises guideline recommendations regarding management of penetrating neck injuries (PNIs) and associated carotid artery injury, for (European) surgeons confronted with this potentially complex problem. When comparing these recommendations to PNI management in two Dutch level 1 trauma centres, it appears that CTA scanning has taken a more prominent role in PNI management than that described in guidelines. Furthermore, to explain clinical decision making, an illustrative case of PNI was added. Objectives: Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective nonoperative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines. Methods: Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case. Results: Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n ¼ 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n ¼ 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n ¼ 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived. Conclusions: This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.

An audit of surgical neck explorations for penetrating neck injuries in northwestern Nigeria: Experience from a teaching hospital

“…Zone II, being the most exposed part of the neck, is the most affected by injuries in our series, as it is reported similarly by most authors worldwide. [ 2 11 13 14 16 17 18 19 20 21 22 23 26 ] The midline of the neck is the most affected side among our patients. A similar finding was reported by de Régloix et al .…”

“…[ 2 11 13 14 16 17 18 19 20 21 22 23 24 ] However, in slight contrast, Seok and Cho[ 25 ] reported a higher median age of 54.3 years, while Hundersmarck et al . [ 26 ] reported a median age of 40 years. These injuries are common in this age group and gender because they constitute the most active part of most societies and are more likely to be exposed to violence and accidents.…”

“…Moreover, most of our patients were hemodynamically stable on presentation, as it is reported by several other authors. [ 2 11 21 26 ]…”

The efficacy of the “no zone” approach for the assessment of traumatic neck injury: a case-control study

“…Therefore, when patients arrive at the hospital, depending on their symptoms and vitality, they may be examined, undergo an operation immediately, or undergo conservative treatments. The clinical significance of the no zone approach, which is based on symptoms, has been reported recently [16,17]. According to Nowicki et al [18], the no zone approach to penetrating neck injury evaluation and management is contemporary and goes against the grain of anatomical zones management.…”

“…However, the number of operation and CT scan trials differed for each study. Hundersmarck et al [17] reported that operation was performed in 54% of total patients, CT scan was 72.1%, and positive FNFs was 53.5%. Ibraheem et al [11] described different results wherein the operation rate was 36.2%, CT scan rate was 66.1%, and positive FNFs rate was 59.8%.…”