Western Trauma Association Critical Decisions in Trauma

Abstract

T his is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their purpose is to succinctly navigate the reader thru the algorithm and discuss those points, which require further elucidation or where data are lacking. 1Y3

Bridging the Gap: A Novel Method for Hemorrhage Control

“…DMP is suggested as a first line response to PNI [6][7][8][9], but is also associated with a low efficacy rate [7]. The low efficacy rate of DMP is not just associated with modest to minimally trained care providers and care location [7,9], but is associated with the skill set required to perform the task [10].…”

“…Delays in establishing definitive control of the airway can make the task of subsequent airway control difficult or impossible because of hematoma formation or injury/resuscitation induced edema leading to subsequent catastrophic airway obstruction [2,5]. The Western Trauma Association (WTA) Critical Decisions in Trauma recommends direct manual pressure (DMP) be used as a first line response to penetrating neck injury [6]. However, this approach has been associated with a low efficacy rate due to re-bleeding and exsanguination prior to reaching definitive operative care [7].…”

Common Carotid Artery Laceration Managed by Clamping at Emergency Department

“…Patients with symptomatic zone II neck injuries should be undergone early operation for neck exploration [3]. In carotid artery injuries ligations, primary repair and interposition with saphenous vein/PTFE graft can be considered [4].…”

Penetrating nontorso trauma: the head and the neck

“…Nontherapeutic neck explorations in this scenario approach 67% in some series. [6][7][8] When patients require investigations to rule out vascular (carotid and vertebral arteries), digestive (esophagus) and/or airway (trachea) injuries, some authors advocate multidetector CT as an isolated test to rule out all 3 systems. 3 Additive bronchoscopy, esophagoscopy and contrast fluoroscopy examinations can also be extremely helpful.…”

“…3 Additive bronchoscopy, esophagoscopy and contrast fluoroscopy examinations can also be extremely helpful. 6,7 The combination of endoscopic and radiologic examination of the esophagus in particular is known to improve the sensitivity of each test in isolation. As always, hard signs of cervical aerodigestive and/or vascular injury mandate immediate operative or percutaneous exploration.…”