Selective management of penetrating neck injuries using “no zone” approach

Abstracts

Introduction

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the “no zone” approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds.

Materials and methods

A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate.

Results

Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%).

Conclusion

Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

Introduction

The neck is an extremely complex anatomical region where several vital structures including blood vessels, aerodigestive tract, spine and spinal cord are confined in a small compact space. Hence, penetration from projectiles or other objects may result in a life-threatening injury. The treatment strategy of penetrating neck injuries (PNIs) acquired from military surgical practice suggested mandatory exploration as a standard treatment to avoid missed injuries [1], [2]. However, civilian adoption of mandatory exploration in PNIs resulted in high negative exploration rate (53–56%) [3], [4], [5]. Selective management of PNIs, using zones of neck injury to guide investigations and management (a “zone-based” approach), has become a widely accepted treatment strategy in the civilian population since this approach carries very low missed injury rates and highly successful non-operative management (NOM) rates (63–66%) [6], [7], [8].

Although zones of neck injury can provide a useful guideline in the management of PNIs, there are some disadvantages related to the use of this zone-based approach including difficulty zoning transcervical or multiple injuries, and poor correlation between the location of neck wounds and internal organ involvement [9]. Therefore, recent studies have given more emphasis to the patients’ signs and symptoms, rather than the neck zones per se, to dictate further investigation and management [10], [11], [12]. This so-called “no zone” approach, using physical examination and computed tomographic angiography (CTA), has greatly simplified the management of PNIs with negligible missed injuries and low negative exploration rates (1–2%) [11], [12], [13]. The purpose of the present study is to identify the outcomes of selective management of PNIs, using the “no zone” approach, in terms of negative exploration rate, missed injury rate, and mortality.