socal acs 2014 - penetrating neck trauma

The Utility of Anatomic “Zones” of the Neck in the Assessment of Penetrating Neck Injury

January 17, 2014

Garren M. I. Low, MS, Kenji Inaba, MD, Konstantinos Chouliaras, MD, Bernardino Branco, MD, Lydia Lam, MD,

Elizabeth Benjamin, MD, Jay Menaker, MD, Demetrios Demetriades, MD, PhD

• No Disclosures

Financial Disclosures

• After WWII• Penetration of the platysma mandated

exploration• 40-60% negative exploration

• Starting in the 1980’s• Neck Zone approach

Background

Zone 1

Zone 2

Zone 3

• Neck zones drive management• Zone II• Zones I & III

Utility of Neck Zone Approach

• Classical imaging for zones I and III• Expensive• Time-consuming• Often negative

• Zone II• Often negative

• Ct angio• Predictive value of external wound

Problems with Zone Approach

• To characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma.• Identify clinical utility of anatomic neck

zone scheme

Objective

• Prospectively collected database• 146 patients

• LAC+USC Medical Center

• 12/2008 through 03/2011

Methods

2012

• All patients underwent structured clinical examination documenting external wound• Senior resident or attending

Methods

Penetrating Neck Injury

Hard Signs OR

Soft Signs Diagnostic Modalities

No Signs Observation• active hemorrhage• expanding or pulsatile hematoma• bruit or thrill in the area of injury• shock unresponsive to initial fluid

resuscitation• massive hemoptysis or hematemesis• air bubbling through the injury site

Penetrating Neck Injury

Hard Signs OR

Soft Signs CT Angio

No Signs Observation• venous oozing• nonexpanding or nonpulsatile

hematomas• minor hemoptysis• dysphonia, dysphagia• subcutaneous emphysema

Penetrating Neck Injury

Hard Signs OR

Soft Signs CT Angio

No Signs Observation

• “Unexpected” internal injury• Internal injury laid outside the borders

of the neck zone corresponding with the external wound

• “Expected” internal injury

Methods

• Age• Mean 31 yo

• Gender• 86% Male

• MOI• 47% GSW• 51% SW

Demographics

Hard Signs

OR

Soft Signs

Diagnostic Modalities

No Signs

Observation

• Hard signs• 32 (22%) patients• Underwent neck exploration

Hard Signs

OR

Soft Signs

CT Angio

No Signs

Observation

• Soft signs• 114 (78%) patients• CT Angio• Management based on

results

Hard Signs

OR

Soft Signs

Diagnostic Modalities

No Signs

Observation

• No signs• Observation• Min 24 hr

Zone 1- 27 patientsZone 2- 57 patientsZone 3- 32 patientsMultiple Neck Zones- 22 patients

No ExternalNeck Wound- 8 patients

• 37 patients with internal neck injury• 50 total injuries

• 44 (88%) were vascular structures• 6 (12%) were aerodigestive tract injuries

Results

• 50 internal injuries• 8 (16%) Unexpected Internal Injuries

• 42 (84%) Expected Internal Injuries

Internal Injuries

• There was a high incidence of non-correlation (16%)

• 6% were not from external neck wounds

• The utility of the anatomic zone approach is questionable.• Clinical presentation

Conclusion