CLINICAL PRACTICE GUIDELINES:

PENETRATING NECK TRAUMA

Samuel A. Tisherman, MD

Faran Bokhari, MD

Bryan Collier, DO

James Ebert, MD

Michele Holevar, MD

John Cumming, MD

Stanley Kurek, DO

Stuart Leon, MD

Peter Rhee, MD

View the guideline
View the evidentiary tables

Correspondence:

Samuel A. Tisherman, MD

Department of Critical Care Medicine

638 Scaife Hall

3550 Terrace Street

Pittsburgh, PA 15261

Phone: 412-647-9914

Fax: 412-802-3308

E-mail: tishermansa@upmc.edu

STATEMENT OF THE PROBLEM

Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent upon the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10-20% with stab wounds.

The management of injuries to the neck that penetrate the platysma is dependent upon the anatomic level of injury. The neck has been decided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between Zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common (1) and can affect length of stay (2). Mortality, particularly for major vascular injuries may reach 50% (3). Delayed complications such as pseudoaneurysms or arterio-venous fistulae can affect long-term outcomes (4). Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, operative management is indicated. Controversy arises over management of the patient without significant symptoms. Our management of these patients has been evolving from an era of mandatory exploration, which led to many non-therapeutic explorations, to an era of more selective management based on clinical experience and new imaging capabilities. Is this justified? What are the specific roles of physical examination and imaging in decision-making? Improved imaging modalities, such as high resolution computed tomography (CT) or specially-performed CT with angiography, might further improve management of these patients. In addition, some injuries to neck structures may not require operative intervention.

Goals of the Guideline

This guideline is designed to answer the following questions regarding the management of penetrating injuries to Zone II of the neck that penetrate the platysma:

1) Is operative management mandatory or is selective non-operative management appropriate?

2) Is physical examination adequate to rule out injuries to vascular structures or the aerodigestive tract?

3) Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary?

4) How should specific vascular injuries be managed?

5) Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury?

6) Is there a need for immobilization of the cervical spine?

II. PROCESS

The process utilized by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed upon the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2006.

Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services as follows: Class I: prospective, randomized, double-blinded study; Class II: prospective, randomized, non-blinded trial; Class III: retrospective series, meta-analysis.

An evidentiary table (Table) was constructed using the 145 references that were identified: Class I, 2 references; Class II, 26 references; and Class III, 105 references. Twelve of the references could not be classified. Recommendations were made on the basis of the studies included in this table. Level 1 recommendations, usually based on class I data, were meant to be convincingly justifiable on scientific evidence alone. Level 2 recommendations, usually supported by class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level 3 recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.

III. Recommendations

A. Selective workup – operation vs selective non-operative management

Recommendations

Level 1:

Selective operative management and mandatory exploration of penetrating injuries to Zone II of the neck are equally justified and safe.

Level 2:

No recommendations.

Level 3:

No recommendations.

Scientific foundation

Nonoperative management of penetrating neck wounds was common in the early 20^th century. Based on a review of civilian experience, Fogelman and Stewart (5) recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. A significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries (6). In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al (7) estimated the cost of a negative exploration at $1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al (8) found that neck explorations under local anesthesia, compared to general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable in the 70s and 80s (9). Some small studies even later recommend mandatory exploration (10). Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed (11-29


		CLINICAL PRACTICE GUIDELINES: PENETRATING NECK TRAUMA Samuel A. Tisherman, MD Faran Bokhari, MD Bryan Collier, DO James Ebert, MD Michele Holevar, MD John Cumming, MD Stanley Kurek, DO Stuart Leon, MD Peter Rhee, MD View the guideline View the evidentiary tables Correspondence: Samuel A. Tisherman, MD Department of Critical Care Medicine 638 Scaife Hall 3550 Terrace Street Pittsburgh, PA 15261 Phone: 412-647-9914 Fax: 412-802-3308 E-mail: tishermansa@upmc.edu STATEMENT OF THE PROBLEM Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent upon the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10-20% with stab wounds. The management of injuries to the neck that penetrate the platysma is dependent upon the anatomic level of injury. The neck has been decided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between Zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common (1) and can affect length of stay (2). Mortality, particularly for major vascular injuries may reach 50% (3). Delayed complications such as pseudoaneurysms or arterio-venous fistulae can affect long-term outcomes (4). Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, operative management is indicated. Controversy arises over management of the patient without significant symptoms. Our management of these patients has been evolving from an era of mandatory exploration, which led to many non-therapeutic explorations, to an era of more selective management based on clinical experience and new imaging capabilities. Is this justified? What are the specific roles of physical examination and imaging in decision-making? Improved imaging modalities, such as high resolution computed tomography (CT) or specially-performed CT with angiography, might further improve management of these patients. In addition, some injuries to neck structures may not require operative intervention. Goals of the Guideline This guideline is designed to answer the following questions regarding the management of penetrating injuries to Zone II of the neck that penetrate the platysma: 1) Is operative management mandatory or is selective non-operative management appropriate? 2) Is physical examination adequate to rule out injuries to vascular structures or the aerodigestive tract? 3) Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary? 4) How should specific vascular injuries be managed? 5) Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury? 6) Is there a need for immobilization of the cervical spine? II. PROCESS The process utilized by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed upon the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2006. Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services as follows: Class I: prospective, randomized, double-blinded study; Class II: prospective, randomized, non-blinded trial; Class III: retrospective series, meta-analysis. An evidentiary table (Table) was constructed using the 145 references that were identified: Class I, 2 references; Class II, 26 references; and Class III, 105 references. Twelve of the references could not be classified. Recommendations were made on the basis of the studies included in this table. Level 1 recommendations, usually based on class I data, were meant to be convincingly justifiable on scientific evidence alone. Level 2 recommendations, usually supported by class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level 3 recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion. III. Recommendations A. Selective workup – operation vs selective non-operative management Recommendations Level 1: Selective operative management and mandatory exploration of penetrating injuries to Zone II of the neck are equally justified and safe. Level 2: No recommendations. Level 3: No recommendations. Scientific foundation Nonoperative management of penetrating neck wounds was common in the early 20^th century. Based on a review of civilian experience, Fogelman and Stewart (5) recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. A significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries (6). In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al (7) estimated the cost of a negative exploration at $1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al (8) found that neck explorations under local anesthesia, compared to general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable in the 70s and 80s (9). Some small studies even later recommend mandatory exploration (10). Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed (11-29