2017-18 HSC Section 3 Green Book

j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 6 ( 2 0 5 ) 4 9 0 e 4 9 8

Table 1 e Signs and findings of injury. Hard signs

Table 2 e Clinical data of patients with PNI investigated with CTA. Variables CTA group

Soft signs

Vascular injury Severe active hemorrhage

n (%)

n ¼ 383 (75.1)

History of severe bleeding or hypotension

Sex

Male (%)

345 (90.1)

Shock not responding to fluids Pulsatile/expanding hematoma

Small-moderate nonexpanding/ pulsatile hematoma

Age in years Mean Neck zone (%) Zone I

Deficit of anatomically related nerve

29.5 (range, 8-78)

Bruit or thrill

On-going venous ooze

162 (42.3)

Central neurologic deficit corresponding to the side of the injury

Hemothorax ( > 500 mL)

Zone II

94 (24.5)

Zone III

30 (7.8)

Multiple zones

59 (15.3)

Pulse discrepancy SBP discrepancy ( > 20 mm Hg) Widened mediastinum on CXR ( > 8 cm at T4 on supine film)

Posterior triangle

36 (9.4)

Undefined

2 (0.5)

Mechanism (%) GSW

ADTI Air bubbling through wound

52 (13.6)

Subcutaneous emphysema

SW

331 (86.4)

Days admitted

Massive Hematemesis

Minor hematemesis or bloody spit

Mean; median

4.3 (range, 0-77); 2 (IQR, 4)

ISS

Massive Hemoptysis

Minor hemoptysis

Mean; median

11.2 (range, 2-75); 9 (IQR, 10)

Saliva leak from wound

Dysphonia/hoarseness/ stridor Odynophagia/dysphagia Deep surgical emphysema on x-ray or CTA

Surgical or endovascular intervention for PNI (%)

66 (17.2%; another two patients had tracheostomy without exploration) 3/383 (0.8%; one of these patients only had a CTA postoperatively)

Nontherapeutic

neck exploration (%)

ADTI ¼ aerodigestive tract injury; CTA ¼ computed tomography angiography; CXR ¼ chest x-ray; SBP ¼ systolic blood pressure.

Mortality (%)

3 (0.8)

CTA ¼ computed tomography angiography; GSW ¼ gunshot wound; IQR ¼ intra quartile range; ISS ¼ injury severity score; PNI, penetrating neck injury; SW, stab wound.

percent (66/383) underwent surgical or endovascular inter- vention for PNI with a rate of negative nontherapeutic neck explorations of only 0.8% (3/383) and a mortality rate of 0.8% (3/383). Table 2 demonstrates this data. A total of 38 patients were diagnosed with a DTI on CTA. A further 11 patients were diagnosed with a DTI by other modalities. Seven pa- tients were taken directly to the operating room due to he- modynamic instability. Another four patients were investigated with flexible endoscopy 1 and water-soluble contrast study. 3 One of these patients was referred to our trauma service a week after sustaining a PNI. He underwent contrast swallow and subsequent debridement of a pharyn- geal injury. No patients who were not immediately explored or imaged with CTA and who were admitted to our service for serial neck examinations were subsequently shown to have a DTI.

A total of 297 patients had negative CTA studies for vascular injury and eight patients indeterminate studies. Ten of 78 positive CTA studies were proven to be false positive for arterial injury and four false negative for vascular injury giv- ing a sensitivity and specificity of CTA for vascular injury of 94.4% (68/[68 þ 4]) and 96.7% (293/[293 þ 10]), respectively. One of the four patients with a false negative CTA study had an isolated venous injury found on exploration for an esophageal injury. One patient was observed in the ward and taken for exploration on the third day post injury, due to an expanding pseudoaneurysm of a branch of the facial artery. The other two with pseudoaneurysms of the costocervical and deep cervical arteries were readmitted 5-20 d postinjury with neck swelling.

CTA for vascular injury

The significance of surgical emphysema on CTA in patients with DTI

Of the 383 patients who underwent a CTA to exclude a vascular injury only 78 (20.4%) had a scan positive for a vascular injury. Fifty-eight studies (15.1%) revealed an arterial injury, and 20 (5.2%) demonstrated an isolated venous injury. In total, 94 vascular injuries were demonstrated on the 78 positive CTA studies of which 61 were arterial and 33 venous.

In total, 38 of 383 (9.9%) patients investigated with CTA for PNI were shown to have sustained a DTI as confirmed either on neck exploration, WS-swallow contrast study, flexible endoscopy or clinical inspection of the wound. These injuries

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