Reliability of Physical Examination as a Predictor of Vascular Injury after Penetrating Neck Trauma

Abstract

The policy of routine angiography (ANG) for all penetrating neck wounds results in a high rate of negative studies. The medical records of all patients who presented to Wishard Memorial Hospital and Methodist Hospital of Indiana with penetrating injuries to the neck from January 1992 to April 2001 were reviewed. All patients who were hemodynamically stable underwent four-vessel ANG to evaluate for vascular injury irrespective of findings on physical examination (PE). A total of 216 patients sustained penetrating neck injuries. Patients were divided according to positive or negative PE findings and the results of ANG. Of the 63 patients with a positive PE, 40 (68%) also had a positive ANG finding. Of the 89 patients with negative PE, only 3 had a positive ANG and none of these injuries required operative repair. PE therefore had a 93 per cent sensitivity (SEN) and a 97 per cent negative predictive value (NPV) for predicting the results of ANG. The SEN and NPV of PE for detecting vascular injuries requiring operative repair were both 100 per cent. In this series, no patient with a negative PE had a vascular injury that required operative repair, irrespective of zone of injury. Routine ANG may therefore be unnecessary for patients with penetrating neck injuries and a negative PE.

Analysis of 203 Patients with Penetrating Neck Injuries

“…The setting of this study is a high‐volume trauma center (~11,000 patients/year) managing a very high number of penetrating trauma victims (~200 PNI/year). Mandatory neck exploration results in a high negative rate (30–89%) in asymptomatic patients [2, 3, 9, 12]. Our management protocol for PNI is based essentially on hemodynamic and airway status, together with the physical examination.…”

“…While some clinicians advocate mandatory neck exploration for asymptomatic patients with PNI [1], selective nonoperative management (SNOM) has slowly gained favor [2][3][4][5][6]. The routine application of specialized diagnostic investigations, some of which are invasive, for stable, asymptomatic patients remains controversial [4,5,[7][8][9][10][11][12][13]. The aim of the present study was to validate a protocol of SNOM of PNI based on history and physical examination, findings of which determine further investigations and management.…”

Multidisciplinary Therapeutic Management in Complex Cervical Trauma

“…There has not yet been a consensus on this. Surgical exploration of all neck injuries beyond the platysma muscle significantly reduced mortality during World War II [ 3 ], but 89% of interventions did not identify deep visceral injuries [ 4 ]. In 1969, Monson et al divided the cervical region into the three zones used in the management of trauma diagnostic protocol [ 5 ].…”

Penetrating Cervical Trauma

“…Continuing experience has confirmed that even patients with modest or moderate symptoms or signs, especially with stab wounds in Zone II, will only have a ''therapeutic'' cervical exploration 55-65 % of the time. Therefore, a selective rather than a mandatory operative approach is the standard of care in asymptomatic patients and in those with modest or moderate symptoms or signs [11][12][13].…”