2017-18 HSC Section 3 Green Book

J Trauma Acute Care Surg Volume 82, Number 6

Tessler et al.

tracheal and esophageal injuries had hard signs of injury. Vital sign ranges and physical examination findings for the different injury groups are provided in Table 5. The sensitivity and specificity of hard signs for injury was 100% (95% confidence interval [CI], 59 – 100%) and 94.4% (95% CI 79 – 99%), respectively, and the sensitivity and specificity of soft signs of injury was 100% (95% CI, 39 – 100%) and 75.5% (95% CI, 60 – 87%), respectively. Given a pediatric penetrating neck trauma prevalence of 0.28% of pediatric trauma, 15 the pos- itive and negative predictive values calculate to 4.8% and 100%, respectively, for both hard and soft signs. Missing data points included prior trauma phase, initial heart rate, and initial MAP for one patient. neck injury in children. We demonstrate that the gradual changes in management of penetrating neck trauma seen in adults have been translated to the children in our series as well. As reflected in Figure 1, the proportion of CTAs increased without a change in the proportion in neck explorations. The number of neck ex- plorations is likely related to the number of salvageable patients who present with hard signs of injury (four between 2005 and 2009, two between 2010 and 2014), whereas CTA clearly emerged as the study of choice in clinically stable patients in the period between 2010 and 2014. The proportions of patients discharged to home or inpatient rehabilitation did not change suggesting no increase or decrease in missed injuries. Three pa- tients over the entire study period without hard signs of injury underwent nontherapeutic neck exploration without preopera- tive cross-sectional imaging. Results from a CTA may have prevented these potentially unnecessary operations. In 2016, Stone and colleagues 15 reviewed 1,238 patients in the National Trauma Data Bank (NTDB) under 15 with pen- etrating neck trauma. This group found that CT scan is the most common imaging obtained and age influenced injury type but not mortality. Our significantly smaller sample differed from those in the NTDB in some notable ways. Stabbing accounted for 44.1% of injury in the NTDB review, whereas only 20.0% of penetrating injuries were of stab wound in our cohort. The av- erage age in our cohort (8.1 years) was similar to the age re- ported from the NTDB; however, we had a lower percentage of male patients (54.5% compared with 70.6%). The median DISCUSSION There have been very few studies focused on penetrating

TABLE 4. Procedures, Injuries, and Deaths

No. (%)

NE, N = 16 NE only

10 (22.7)

NE, laryngoscopy/bronchoscopy

2 (4.5) 1 (2.3) 3 (6.8)

NE, esophagoscopy

NE, bronchoscopy/esophagoscopy/Upper GI fluoroscopy

Endoscopy, N = 2 Esophagoscopy

1 (2.3)

Bronchoscopy

0

Esophagoscopy/Bronchoscopy

1 (2.3)

Injuries or death (N = 13, includes patients with multiple injuries) Vascular

8 (18.2) 1 (2.3) 1 (2.3) 3 (6.8) 3 (6.8) 2 (4.5)

Trachea

Esophagus

Nerve

Foreign body

Deceased

NE, neck exploration.

decrease in standard CT scans, and no change in neck explora- tions or proportions discharged to home. These differences trend toward but are not statistically significant for the cross-sectional imaging variables. Neck Exploration and Supplemental Procedures Ten patients underwent neck exploration, and six underwent neck exploration with a supplementary procedure such as en- doscopy or fluoroscopy (Table 4). Two patients underwent endoscopy alone. Two patients with cross-sectional imaging went on to endoscopy, and five patients went on to neck exploration with or without endoscopy. Foreign bodies were recovered in two of these five patients during neck exploration, and three injuries were discovered in the others. The two patients with imaging followed by endoscopy did not have injuries. Of the 16 neck explorations, procedures were performed for associated injuries in three patients, and eight patients underwent procedures for associated injuries without neck exploration. Injuries (including foreign body requiring removal) were discovered in 13 patients with over half of injuries being vascu- lar. One tracheal injury, one esophageal injury, and three nerve injuries were also discovered. Three foreign body removals were performed at neck exploration. Two patients died before explo- ration. Of the two deaths, one was due to an associated head in- jury. Of the surviving 42 patients, 40 were discharged to home and the remaining two patients were discharged to acute inpa- tient rehabilitation. Nineteen total patients had associated inju- ries with eight in the extremities, 10 associated head injuries, and five associated thoracic injuries. Of the 10 patients with hard signs, six had a major injury and two died. Eight patients with only soft signs did not undergo neck exploration and four underwent cross-sectional imaging. All were discharged home without issue. Of the eight patients with a vascular injury, four had hard signs and four had only soft signs. Both patients with Injuries, Hard, and Soft Signs

TABLE 5. Injuries and Associated Findings

Vascular (n = 8) Trachea (n = 1) Esophagus (n = 1)

Hard signs (any) Soft signs only

4 4 0

1 0 0

1 0 0

No hard or soft signs

Heart rate, bpm MAP, mm Hg

92 – 145 67 – 109

107

120

92

43

GCS

13 – 15 100%

3

3

Oxygen saturation

100%

100%

*Foreign body and nerve injuries not included.

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