2017-18 HSC Section 3 Green Book

J Trauma Acute Care Surg Volume 82, Number 6

Tessler et al.

represented after discharge or to another hospital without being captured in this study. The interpretation of these data is also limited by the retrospective design and the imperfections of re- cord keeping, especially older handwritten charts. Zone II inju- ries predominated the study subjects and so extrapolating to zone I and zone III should be done with caution. Also, the au- topsy reports with injuries for the two deceased patients were not available for inclusion. Despite these limitations, our data collection efforts achieved highly complete data for analysis. Experience with pediatric penetrating neck trauma is lim- ited. Management algorithms should ideally evolve from pediat- ric specific data. The experience reported here further supports the applicability of selective observation in clinically normal pe- diatric patients with penetrating neck injury. CTA is the initial study of choice for cross-sectional imaging and physical exami- nation data, specifically the hard and soft signs of injury, are crit- ically informative to management decisions. AUTHORSHIP R.A.T., H.N., C.N., and J.B. designed the study. R.A.T. performed data analysis, wrote and edited the majority of the article. H.N. collected the data, contributed to exploratory statistical analysis, and wrote portions of the article. C.N. and J.B. edited the article and advised statistical analysis. REFERENCES 1. Abujamra L, Joseph MM. Penetrating neck injuries in children: a retrospec- tive review. Pediatr Emerg Care . 2003;19(5):308 – 313. 2. Tisherman SA, Bokhari F, Collier B, Cumming J, Ebert J, Holevar M, Kurek S, Leon S, Rhee P. Clinical practice guideline: penetrating zone II neck trauma. J Trauma . 2008;64(5):1392 – 1405. 3. Hussain Zaidi SM, Ahmad R. Penetrating neck trauma: a case for conserva- tive approach. Am J Otolaryngol . 2011;32(6):591 – 596. 4. Prichayudh S, Choadrachata-anun J, Sriussadaporn S, Pak-art R, Sriussadaporn S, Kritayakirana K, Samorn P. Selective management of penetrating neck injuries using “ no zone ” approach. Injury . 2015;46(9):1720 – 1725. 5. Hall JR, Reyes HM, Meller JL. Penetrating zone-II neck injuries in children. J Trauma . 1991;31(12):1614 – 1617. 6. Hackett AM, Chi D, Kitsko DJ. Patterns of injury and otolaryngology intervention in pediatric neck trauma. Int J Pediatr Otorhinolaryngol . 2012; 76(12):1751 – 1754. 7. KimMK, Buckman R, Szeremeta W. Penetrating neck trauma in children: an urban hospital's experience. Otolaryngol Head Neck Surg . 2000;123(4): 439 – 443. 8. Vick LR, Islam S. Adding insult to injury: neck exploration for penetrating pediatric neck trauma. Am Surg . 2008;74(11):1104 – 1106. 9. Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, McIntyre RC Jr, Moore FA, Malhotra A, Shatz DV, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg . 2013;75(6):936 – 940. 10. Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiogra- phy as an aid to clinical decision making in the selective management of pen- etrating injuries to the neck: a reduction in the need for operative exploration. J Trauma . 2008;64(6):1466 – 1471. 11. Inaba K, Branco BC, Menaker J, Scalea TM, Crane S, DuBose JJ, Tung L, Reddy S, Demetriades D. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg . 2012;72(3):576 – 583; discussion 583 – 4. 12. Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically DISCLOSURE The authors declare no conflicts of interest.

ISS from NTDB was 4 and roughly one quarter went directly to the operating room compared with a median ISS of 2 (mean, 8.6; SD, 10.5) in our patients. Over 36% of our patients underwent immediate neck exploration. The vast majority of injuries re- ported from the NTDB were aerodigestive (82.7%) compared with primarily vascular and soft tissue injuries in our group of pa- tients. Interpretation of these differences is difficult given the small sample size in our study and differences in the periods, 2008 to 2012, and 2001 to 2014, in the two data sets. The small sample size also limits our ability to stratify injuries based on age, as performed with the NTBD. The differences in sex may re- flect particularities to the catchment served by this pediatric Level 1 trauma center. Of the limited studies of penetrating neck trauma in children, this is the largest series to report complete physical examination data with hard and soft signs of injury. 7,8,16 In our series, airway compromise and active hemorrhage were the most common hard signs of injury. Of the eight patients with hard signs who sur- vived to neck exploration, clinically significant injuries were identified in six. Of the available data reported from the NTDB, hypotension in the emergency department occurred in 8.2% of patients, far less than the percentage reported that underwent op- erative exploration. This suggests that additional clinical data in- fluenced decisions to operate. Similarly, our data on vital signs only demonstrate a single hypotensive value among the explored patients. These data support the notion that hypotension is a po- tentially late sign of decompensation and clinical indications for operative exploration, such as hard signs of injury on physical examination, are usually present before hypotension appears. A group in Thailand reported on their 10-year experience caring for 86 adults with penetrating neck injury that included 36 patients with hard signs of injury and two negative neck ex- plorations. 4 This computes to a sensitivity of 100% and specific- ity of 96.1% for hard signs, similar to the data presented here. In 1997, Demetriades and coauthors 17 examined the hard signs of injury in adults with penetrating neck injury prospectively with the adjunct of angiography and color Doppler and found the ab- sence of hard signs to have a 100% negative predictive value. These data combined with our results suggest that the hard signs of injury, or their absence, are similarly reliable in children as previously demonstrated in adults. The sensitivity and specificity of soft signs in a pediatric patient with penetrating neck injury also can be useful. Kim and coauthors 7 reported on selective neck explorations for six patients with stridor, dysphagia, a changing neck examination, and a foreign body. Four of these patients underwent panendoscopy and neck exploration with tracheal, laryngeal, esophageal, and soft tissue injuries discovered and managed. Our series again has a higher proportion of vascular to aerodigestive injuries than reported in other cohorts. Numbers are likely too small to suggest theories on the true presence or absence of different injury patterns. This study has several limitations, most obviously, the small sample of patients. Thankfully, this is a rare occurrence in children, and efforts to share institutional trauma information would increase the numbers of patients without sacrificing gran- ularity of data, a crucial component for this injury. This might be one strategy to address studying rare injuries with nuanced clin- ical decision making. Given our data are confined to the hospital admission, patients with missed injuries could have theoretically

© 2017 Wolters Kluwer Health, Inc. All rights reserved.

67