Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem

Abstract

Objectives: Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective non-operative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines.

Methods: Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case.

Results: Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n = 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n = 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n = 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived.

Conclusions: This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.

Keywords: Carotid artery injury; Penetrating neck injury; Selective management; Trauma centre.