Purpose
Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone‐based approach to a ‘no zone’ ...algorithm, resulting in reduced non‐therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a ‘no zone’ approach could be safely implemented in this population, as has been demonstrated internationally.
Methodology
This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT‐A) use and operative intervention. Patients were examined based on zone of injury and presenting signs – ‘hard’, ‘soft’ or ‘asymptomatic’. Major outcomes were CT‐A usage, positive CT‐A correlation with therapeutic neck explorations and negative neck exploration rates.
Results
This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT‐A utilization increased from 55% to 94.1%, with positive CT‐As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non‐therapeutic neck explorations.
Conclusion
Our data suggests similarities with results from around the world, demonstrating that the ‘no zone’ approach should be considered when managing PNIs, but with clinician discretion in individual cases.
Trend of CT‐A, operative and therapeutic rates over a 10‐year period from 2008 to 2018.
Evaluation of Nonfatal Strangulation in Alert Adults Matusz, Erin C.; Schaffer, Jason T.; Bachmeier, Barbra A. ...
Annals of emergency medicine,
March 2020, 2020-03-00, 20200301, Letnik:
75, Številka:
3
Journal Article
Recenzirano
There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to ...define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries.
Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours’ observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries.
Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations.
Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.
•Directed work-up with CTA and diagnostic studies is associated with fewer non-therapeutic neck explorations.•There were no differences in stroke, leak, or length of stay when directed work-up was ...compared to immediate operative intervention.•When stratified by hard signs, there was no difference in mortality between directed work-up and immediate operative intervention.
Management of penetrating neck injuries (PNIs) has evolved over time, more frequently relying on increased utilization of diagnostic imaging studies. Directed work-up with computed tomography imaging has resulted in increased use of angiography and decreased operative interventions. We sought to evaluate management strategies after directed work-up, hypothesizing increased use of non-operative therapeutic interventions and lower mortality after directed work-up.
Patients with PNI from 2017 to 2022 were identified from a single-center trauma registry. Demographics, injuries, physical exam findings, diagnostic studies and interventions were collected. Patients were stratified by presence of hard signs and management strategy directed work-up (DW) and immediate operative intervention (OR) and compared. Outcomes included therapeutic non-operative intervention endovascular stent, embolization, dual antiplatelet therapy (DAPT), or anticoagulation (AC), non-therapeutic neck exploration, length of stay (LOS), and mortality.
Of 436 patients with PNI, 143 (33%) patients had vascular and/or aerodigestive injuries. Of these, 115 (80%) patients underwent DW and 28 (20%) patients underwent OR. There were no differences in demographics or injury severity score between groups. Patients in the DW group were more likely to undergo vascular stent or embolization (p = 0.040) and had fewer non-therapeutic neck explorations (p = 0.0009), compared to the OR group. There were no differences in post-intervention stroke, leak, or mortality. Sixty percent of patients with vascular hard signs and 78% of patients with aerodigestive hard signs underwent DW.
Directed work-up in select patients with PNI is associated with fewer non-therapeutic neck explorations. There was no difference in mortality. Selective use of endovascular management, AC and DAPT is safe.
Background:
Few studies have documented catastrophic head and neck injuries in judo, but these injuries deserve greater attention.
Purpose:
To determine the features of catastrophic head and neck ...injuries in judo.
Study Design:
Descriptive epidemiological study.
Methods:
This study was based on the accident reports submitted to the All Japan Judo Federation’s System for Compensation for Loss or Damage. A total of 72 judo injuries (30 head, 19 neck, and 23 other injuries) were reported between 2003 and 2010. The investigated parameters were mechanism of injury, age at time of injury, length of judo experience, diagnosis, and outcome.
Results:
Among head injuries, 27 of 30 (90%) occurred in players younger than 20 years of age. The relationship between age, mechanism, and location of injury was more relevant when players younger than 20 years incurred head injury while being thrown (P = .0026). Among neck injuries, 13 of 19 (68%) occurred in players with more than 36 months of experience. The relationship between experience, mechanism, and location of injury was more relevant when experienced players incurred neck injury while executing an offensive maneuver (P = .0294). Acute subdural hematoma was diagnosed in 94% of head injuries. The outcomes of head injury were as follows: 15 players died; 5 were in a persistent vegetative state; 6 required assistance because of higher brain dysfunction, hemiplegia, or aphasia; and 4 had full recovery. Among neck injuries, 18 players were diagnosed with cervical spine injury, 11 of whom had fracture-dislocation of the cervical vertebra; there was also 1 case of atlantoaxial subluxation. The outcomes of neck injury were as follows: 7 players had complete paralysis, 7 had incomplete paralysis, and 5 had full recovery.
Conclusion:
Neck injuries were associated with having more experience and executing offensive maneuvers, whereas head injuries were associated with age younger than 20 years and with being thrown.
Young adults who present to the ED with neck pain following non‐penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport‐related neck ...injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front‐line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi‐disciplinary team management of this condition. In general, guideline‐based recommendation for the management of neck artery dissection involving an intimal flap is by anti‐platelet therapy while treatment of neck artery dissection that results in a pseudo‐aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.
The diagnosis of a young adult with neck artery dissection is challenging especially with seemingly trivial presentations. We review the literature and discuss typical mechanism of injury, symptoms and clinical aids in diagnosis in the ED.
Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma ...center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.
External laryngeal trauma is a rare but potentially fatal event that presents several management challenges. This retrospective observational case series conducted at a level-1 trauma center over a ...12-year period consists of 62 cases of acute external laryngeal trauma. Patient demographics, mode and mechanisms of injury, presenting signs and symptoms, initial imaging results, airway management, time to surgical management, and 6-month outcomes including airway status, deglutition status, and voice quality were investigated. No difference was found in mortality or 6-month outcomes between patients requiring surgical repair and/or tracheostomy versus patients with less severe injuries managed conservatively.
Background
Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT.
Methods
Adult patients with ...PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes.
Results
During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48–72 h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound.
Conclusion
This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.
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