2017-18 HSC Section 3 Green Book

J Trauma Acute Care Surg Volume 82, Number 6

Tessler et al.

than 95%, it falls dramatically for diagnosis of aerodigestive in- juries. 9,11,12 In addition to physical examination, the Western Trauma Association guidelines recommend computed tomogra- phy angiography (CTA) of the neck and chest to evaluate for aerodigestive and vascular injuries in clinically stable adults with Zone I, II, and III injuries. In addition to detecting vascular compromise, CTA has reported high sensitivity for detecting in- juries to the trachea and/or esophagus in adults. 13 There is a paucity of published data on neck trauma in children. More information is emerging to support selective sur- gical exploration; however, definitive algorithms to guide clini- cians have not yet been proposed. Our objective is to describe our experience caring for pediatric penetrating neck trauma over a 14-year period, report the sensitivity and specificity of the physical examination for predicting injury discovered at neck exploration, and describe trends in management over the study period. Regarding identification of injuries, we hypothesize that the physical examination is reliable and CTA is becoming more commonly utilized as a diagnostic tool in the evaluation of a clinically stable pediatric patient with penetrating neck trauma, similar to the management strategies seen in adults. 14 METHODS UCSF Benioff Children ’ s Hospital Oakland (BCHO) is a Level 1, urban, pediatric trauma center. All children younger than 18 years with injuries to the neck between the years of 2001 and 2014 were identified from the BCHO trauma registry based on International Classification of Diseases 9th Revision codes of 874 (open wound of neck), 925.2 (crushing injury of neck), and 959.09 (other and unspecified injury to face and neck). Patients who sustained an injury to the vertebral column or cervical spinal cord were excluded. Medical records were re- viewed and those with a penetrating injury were selected for in- clusion. Information on demographics, mechanism, vital signs, physical examination, imaging, procedures, injuries, injury se- verity, and disposition were collected from the trauma database and from medical records. Physical examination data of pene- trating neck injuries were reviewed by a senior pediatric surgeon and categorized into hard signs (active hemorrhage, airway com- promise, air bubbling wound, expanding/pulsatile hematoma, hematemesis, hemiparesis, massive subcutaneous emphysema, pulse deficit, respiratory distress, shock), soft signs (neck bruit, chest tube air leak, dysphagia, dyspnea, hemoptysis, laceration >2 cm, minor hemoptysis, nonpulsatile/nonexpanding hema- toma, parasthesias, stridor, venous oozing, voice changes), and neck zone. Of note, the categories “ venous oozing ” and “ lacera- tions >2 cm ” were included as soft signs specific to pediatric pa- tients. These additions were related to the inability of young children to tolerate bedside closure or hemostatic suture place- ment as well as the relative size of a 2-cm laceration on a smaller sized neck. Consequently, these features may prompt a minimal operative exploration under general anesthesia primarily to ad- dress wound related issues. However, further investigation into the wound depth and involved structures may also be simulta- neously accomplished. Similar categories have been incorpo- rated in prior studies of pediatric penetrating neck injury. 1 Injuries to the trachea, esophagus, named nerves, or named vascular structures were considered major injuries. Patients who

did not have a major injury were categorized into the “ no major in- juries ” group. Neck explorations included patients who underwent surgical exploration in the operating room, including soft tissue washout or foreign body removal. If patients underwent neck ex- ploration or endoscopy, only imaging data obtained before the pro- cedure was included for analysis. Descriptive statistical analysis was performed for continu- ous and categorical variables. Sensitivity and specificity were calculated for the hard and soft signs of injury. Procedures and imaging were analyzed and categorized using subdivisions of the study period into approximate thirds, 2001 to 2004 (4 years), 2005 to 2009 (5 years), and 2010 to 2014 (5 years) to detect trends in clinical management. Proportions of patients who re- ceived computed tomography (CT) of the head/neck/face, CTA, and neck exploration were compared between the periods using a χ 2 test. Injury and procedure counts were performed within categories of hard/soft signs and vital sign ranges. For- eign body removal and peripheral nerve injuries were not consid- ered in these counts or calculations as the predictive variables of interest (physical examination and vital signs) concern vascular and aerodigestive injury. Data were stored and analyzed in Microsoft Excel 2010 and Microsoft Access 2010. This study was approved by the Institutional Review Board of Children's Hospital Oakland Research Institute. The BCHO trauma registry identified 44 patients with penetrating neck injuries from 2001 to 2014. The majority of these patients were male (55%) and the median agewas 7.3 years ranging from 8 months to 18 years. The four most common mechanisms were gunshot (25%), fall onto a sharp object (22%), dog bite (20%), and stabbing (20%). The median Injury Severity Score was 2 (IQR, 1 – 11.5), and most patients (75%) presented from the field (Table 1). Vital signs on presentation are shown in Table 2. Mean arterial pressure (MAP) was greater than 50 mm Hg in over 95% of patients, and the heart rate was greater than 110 beats per minute in 51.1% of patients. Thirty-seven patients (84%) had a Glasgow Coma Score between 13 and 15 and only two patients demonstrated oxygen saturation less than 90%. Physical Examination and Zone of Injury Thirty-two patients had a zone II penetrating injury and six patients had a combined zone II and zone III penetrating in- jury. Ten patients had hard signs of injury, and 16 patients had soft signs of injury without associating hard signs. Hard signs of injury sustained by our cohort included active hemorrhage, airway compromise, respiratory distress, massive subcutaneous emphysema, hemiparesis, and shock. Soft signs of injury were mostly lacerations greater than 2 cm and venous oozing. Table 3 shows the frequency of each hard or soft sign. Supplemental Digital Content 1 (http://links.lww.com/TA/A894) demonstrates the phys- ical examination findings by zone of injury. Imaging Imaging was obtained in 18 patients as part of the initial evaluation. In the period from 2001 to 2004, three of eight total patients had standard CT scans of the head/neck/face using RESULTS Presentation to the Trauma Service

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