2017-18 HSC Section 3 Green Book

Reprinted by permission of J Trauma Acute Care Surg. 2017; 82(6):989-994.

PTS P LENARY P APER

Pediatric penetrating neck trauma: Hard signs of injury and selective neck exploration

Rober A. Tessler, MD, Huong Nguyen, Christoper Newton, MD, and James Betts, MD , Oakland, California

BACKGROUND:

Selective neck exploration and computed tomography angiography (CTA) in penetrating neck trauma have been well described in adults. However, data in the pediatric population are sparse. The extent to which these practices have been adopted in pediatric pa- tients is unknown. Retrospective, single-center cohort study of pediatric penetrating neck trauma for the years 2001 to 2014 in a dedicated children's hospital/Level 1 pediatric trauma center. Clinical data, sensitivity and specificity of hard signs (active hemorrhage, airway compro- mise, expanding hematoma, crepitus, and so on) and soft signs of injury (bruit, voice change, stridor, laceration less than 2 cm, nonexpanding hematoma, and so on), and trends in imaging were examined. A total of 44 patients were identified with penetrating neck trauma. The majority of these patients were male (55%) aged 8 months to 18 years and a median of 7.3 years. Sixteen patients underwent neck exploration with 13 major injuries identified in 10 patients. Nineteen patients had associated injuries. Ten patients had at least one hard sign of injury, and 16 patients had only soft signs of injury. The sensitivity and specificity of hard signs of injury were 100% (95% confidence interval [CI], 59 – 100%) and 94.4% (95% CI, 79 – 99%), respectively. Soft signs only had a sensitivity and specificity of 100% (95% CI, 39 – 100%) and 75.5% (95% CI, 60 – 86%), respectively. Positive and negative predictive values were 4.8% and 100%, respectively, for both hard and soft signs. The number of CTA studies increased over time but was not statistically significant. Forty (90%) patients were discharged home and two patients died. These results suggest that management of penetrating neck trauma in children includes selective neck exploration based on phys- ical examination and the use of CTA in stable patients, similar to current adult recommendations. We did not observe evidence of missed injuries over the study period. ( J Trauma Acute Care Surg. 2017;82: 989 – 994. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

METHODS:

RESULTS:

CONCLUSION:

LEVEL OF EVIDENCE: Therapeutic/care management, level IV. KEY WORDS:

Pediatric neck trauma; penetrating neck trauma; CT angiography; hard signs of injury.

N eck trauma in children is thankfully a rare occurrence, 1 with challenges. Because of the density of critical anatomic structures in a small area, penetrating neck trauma can have dev- astating consequences. However, neck exploration in children can be particularly challenging with significant risk of causing even further injury. Attempts to avoid negative neck exploration can in- crease the risk of missing injuries and delaying vital repairs. Diag- nostic maneuvers such as endoscopy and angiography also have associated difficulty and risk in children compared to adults. Traditional teaching in the management of penetrating neck trauma in adults has seen updates in the more recent Submitted: November 19, 2015, Revised: January 19, 2017, Accepted: February 8, 2017, Published online: March 14, 2017. From the Department of Surgery (R.A.T.), UCSF East Bay; Division of Pediatric Surgery and Trauma Services (H.N.), UCSF Benioff Children ’ s Hospital Oakland, Oakland, California; Trauma Division of Pediatric Surgery and Trauma Services (C.N.), and Surgery Division of Pediatric Surgery and Trauma Services (J.B.), UCSF Benioff Children ’ s Hospital Oakland, Seattle, Washington. This study was presented at the 2nd annual meeting of the Pediatric Trauma Society, November 6 – 7, 2015, in Scottsdale, Arizona. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal ’ s Web site (www.jtrauma.com). Address for reprints: Robert Tessler, MD, UCSF East Bay Department of Surgery, QIC 22134, 1411 East 31 st Street, Oakland, CA 94602; email: robert.tessler@gmail.com.

literature, where previously mandated surgical exploration is now reserved for particularly concerning clinical scenarios. 2 – 4 Data to guide clinical decision-making in the pediatric patient with a penetrating injury to the neck are far less robust. Recent literature has suggested that many clinically stable pediatric pa- tients with penetrating neck trauma can be safely observed with- out immediate exploration. 5 – 8 To better characterize injuries in the neck, three anatomic zones have been described. 9 Zone II of the neck is defined as the area between the cricothyroid membrane and the angle of the mandible, and is the area most frequently requiring surgery. Management of penetrating neck trauma in zone II evolved over the last half century fromobligatory operative exploration to selective observation in clinically stable patients. 10 The hard signs of injury that continue to mandate exploration include active hemorrhage, pul- satile or expanding hematoma, pulse deficit, massive subcutaneous emphysema, respiratory distress, shock, and airway compromise. Experts have also described soft signs of injury in adults includ- ing hoarseness, dysphagia, odynophagia, palpable crepitus, a stable hematoma, and any neurologic changes. 2,9 The most re- cent guidelines proposed by the Western Trauma Association on penetrating neck trauma in adults recommend nonoperative management in clinically stable patients without dysphagia, voice change, hemoptysis, hematemesis, abnormal x-ray findings, or bruits/thrills. 9 Although the sensitivity of the physical examina- tion for detecting arterial injuries has been reported at greater

DOI: 10.1097/TA.0000000000001407

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