foley catheter balloon tamponade for penetrating …
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University of Cape Town
Department of Surgery
FOLEY CATHETER BALLOON TAMPONADE FOR
PENETRATING NECK INJURIES AT GROOTE SCHUUR
HOSPITAL: AN UPDATE
Dr Matthias Frank Scriba
SCRMAT001
SUBMITTED TO THE UNIVERSITY OF CAPE TOWN
In fulfilment of the requirements for the degree of
MASTERS OF MEDICINE IN SURGERY
Faculty of Health Sciences
University of Cape Town
January 2020
Supervisor:
Professor Pradeep Navsaria
University of Cape Town
Department of Trauma Surgery, Groote Schuur Hospital
Univers
ity of
Cap
e Tow
n
The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non-commercial research purposes only.
Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.
Univers
ity of
Cap
e Tow
n
2
TABLE OF CONTENTS
DECLARATION 3
ACKNOWLEDGEMENTS 4
LIST OF FIGURES AND TABLES 5
ABBREVIATIONS 6
ABSTRACT 8
LITERATURE REVIEW 10
Introduction 10
Historical Perspective 10
Demographics and Outcomes 11
Management Strategies in Penetrating Neck Injuries 14
Investigations for PNI 17
Management of Vascular Injuries 19
Foley Catheter Balloon Tamponade (FCBT) 19
Definitive Management of Vascular Injuries 24
Conclusion 26
References 27
PUBLICATION READY MANUSCRIPT 31
Introduction 31
Methods 31
Results 33
Discussion 38
Conclusion 41
Tables and Figures 42
References 51
Appendices 52
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DECLARATION
I, Matthias Frank Scriba, hereby declare that the work on which this dissertation/thesis is based is my
original work (except where acknowledgements indicate otherwise) and that neither the whole work
nor any part of it has been, is being, or is to be submitted for another degree in this or any other
university.
I empower the university to reproduce for the purpose of research either the whole or any portion of
the contents in any manner whatsoever.
Signature:
Date: 5th January 2020
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ACKNOWLEDGEMENTS
I would like to express my sincere gratitude to my supervisor Professor Pradeep Navsaria for his
guidance and support which have made this study and manuscript possible.
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LIST OF FIGURES AND TABLES
Literature Review
Tables
Table 1. Comparison of international and South African PNI studies
Table 2. Hard and soft signs of vascular and aerodigestive tract injuries
Table 3. Comparison of vascular imaging modalities for PNI
Table 4. Comparison of recent PNI studies that include FCBT
Figures
Figure 1. Anatomical zones for penetrating neck injury
Figure 2. Technique of Foley catheter insertion for penetrating neck injury
Figure 3. Algorithm for Foley catheter balloon tamponade in penetrating neck injury
Manuscript
Tables
Table 1. Recent PNI reports that include FCBT
Table 2. Admission vital signs an injury severity scores in 95 patients
Table 3. Facility designation and number of catheters placed per patient.
Table 4. Foley Catheter Placement Complications
Table 5. Vascular injuries identified
Table 6. Overall Morbidities
Figures
Figure 1. Algorithm for Foley catheter balloon tamponade in penetrating neck injury
Figure 2. Photograph of patient with left neck stab wound who required the insertion of 4 Foley
catheters to arrest active bleeding.
Figure 3. Successful FCBT for actively bleeding right-sided zone I neck stab with subclavian artery
injury.
Figure 4. Summary of Arterial and Venous Injuries
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ABBREVIATIONS
ATLS = Advance Trauma Life Support
CDA = Catheter-directed angiography
CT = Computerised tomography
CTA = Computerised tomography angiography
DSA = Digital subtraction angiography
EAST = Eastern Association for the Surgery of Trauma
FC = Foley catheter
FCBT = Foley catheter balloon tamponade
GCS = Glasgow Come Scale
GSH = Groote Schuur Hospital
GSW = Gunshot wounds
IQR = Interquartile range
ISS = Injury Severity Score
MRA = Magnetic resonance angiography
NISS = New Injury Severity Score
NM = Not mentioned
NOM = Non-operative management
OR = Operating room
PNI = Penetrating neck injury
RTS = Revised Trauma Score
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SW = Stab wounds
TRISS = Trauma and Injury Severity Score
USA = United States of America
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ABSTRACT
Introduction
Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is an
effective, readily available and easy-to-use technique. This study aims to audit the technique and
highlight current investigative and management strategies.
Methods
All adult patients (18 years and older) with PNIs requiring FCBT presenting to Groote Schuur
Hospital (GSH) within a 22-month study period were included. Data were captured on an approved
electronic registry and analysed. Parameters analysed included demographics, major injuries,
radiological imaging, management and outcomes.
Results
Over the study period a total of 628 patients with PNI were managed at GSH, in which 95 patients
(15.2%) FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most
injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior
to arrival at GSH (1.1% prehospital, 45.3% at clinic level and 34.7% at district hospital level).
Computerised tomography angiography (CTA) was used in 92.6% of patients, while 8 patients (8.4%)
required catheter-directed angiography. Of these, two were diagnostic and 6 were performed for
interventional endovascular management. A total of 34 arterial injuries were identified in 29 patients.
Ongoing bleeding was noted in only three patients, equating to a 97% success rate for haemorrhage
control. Thirteen (13.7%) patients required open neck surgery. Seventy-two (75.8%) patients without
major arterial injury had removal of the catheter at 48-72 hours post injury. Only two of these had
bleeding on catheter removal. Fifteen patients required ICU admission. A total of 36 separate
morbidities were documented in 28 patients (29.5%). There was only one death attributable to
uncontrolled haemorrhage from the neck wound.
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Conclusion
This large series shows the current use of FCBT for PNI. It highlights ease of use, high rates of
success at haemorrhage control (97%) and good outcomes. Venous injuries and minor arterial injuries
can be managed with this technique definitively.
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LITERATURE REVIEW
INTRODUCTION
The medical literature is abundant with reports on penetrating neck injury (PNI). These range from
case reports and series of historical interest, to more recent larger civilian cohorts with up-to-date
recommendations, guidelines and algorithms for the contemporary management of such injuries.
Despite these recommended protocols, the management of penetrating neck injuries (PNIs) remains
controversial. This current literature review focuses on vascular injuries associated with penetrating
neck trauma.
HISTORICAL PERSPECTIVE
Penetrating trauma to the neck has been described as far back as 1600 BC in the Edwin Smith
Surgical Papyrus [1], which contains 48 trauma case studies, including a penetrating cervical spine
injury (case #30) [2] and an oesophageal injury (case #28) [3] both from stab wounds. Ambrose Pare
in 1552 ligated both a common carotid artery and jugular vein injury in a soldier with a penetrating
neck wound. The soldier reportedly developed significant central neurology, but survived [4]. The
first successful carotid artery ligation without neurological sequelae was performed by Fleming in
1803 [4].
The current accepted approach seems to have gone full circle from complete non-surgical
management, to an era of mandatory surgical exploration to a more recent, well established highly
selective operative approach. Non-operative management was considered the standard of care up to
the First World War (1914 – 1918) with mortality rates of around 15 % [3, 4]. By the time the Second
World War (1939 – 1945) was fought, surgical exploration consisting mainly of ligation of injured
cervical vessels, was the order of the day. Mandatory surgical exploration became the standard of care
during the Vietnam War (1955 – 1975). This approach was transferred to the civilian setting, where
urban trauma centres advocated that all injuries breaching the platysma warranted surgical exploration
[3, 4]. However, more recently, management strategies have once again swung towards a more
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conservative approach, with selective non-operative management, following a thorough clinical
examination and aggressive diagnostic investigative algorithm, considered now to be the standard of
care [5, 6].
DEMOGRAPHICS AND OUTCOMES
Penetrating neck injuries are seen the world over, but prevalence varies greatly in different parts of the
globe. Case series from Europe and East Asia show a low prevalence of PNI. In their case series from
France, de Régloix et al [7] encountered an average of 2 patients with PNI per month over their 2-year
study period, while Kasbekar et al [8] (England) and Prichayudh et al [9] (Thailand) had an average
of less than 1 patient per month in their case series. Case series from the United States of America
have a higher prevalence. Demetriades et al [10] encountered an average of 11 patients per month,
while a more recent case series from 2018 by Ibraheem et al [11], had an average of 4 patients per
month. In comparison, South African studies show a much higher prevalence of PNI, with monthly
averages ranging between 11 and 19 patients per month [12, 13, 14, 15, 21].
Contrary to this difference in prevalence, demographics of PNI patients are quite similar in all
regions. All studies show a significant young adult male predominance. Low-velocity gunshot and
knife wounds are the predominant injuring mechanisms. Other less common mechanisms, such as
debris acting as a projectile are also described [7]. In most papers, knife stabbings are by far the most
prevalent, however some studies show a much higher rate of gunshot wounds [10]. Table 1 compares
international and South African PNI demographics, mechanisms of injury, surgical management and
outcomes.
Patient outcomes from PNIs vary, but seem to reflect relatively good outcomes considering the
abundance of vital structures contained so close together in a small, confined space. A number of
studies report no deaths [13, 14, 16], while others reveal mortality rates ranging from 1.8% - 11%.
These recorded mortalities however reflect in-hospital mortality only and do not consider those
patients dying at the scene or en-route to hospital. This is highlighted by McQuaide & Villet [18]. In
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their series of 266 patients with PNI, 9 in-hospital deaths were encountered. During the same period a
further 108 PNI cases were seen at the Government mortuary, suggesting an overall PNI mortality
rate of 32.3%. Madsen et al [15], in a more recent study, showed an in-hospital mortality rate of 2%.
Only 10 patients in their cohort of 510 PNI patients died while in hospital. However, mortuary data
from the same study period revealed a further 102 deaths attributed to PNI, raising the overall
mortality rate attributable to PNI to 17% [15].
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Table 1. Comparison of international and South African PNI studies (N = total patient number; SW = stab wounds; GSW = gunshot wounds; NOM = non-operative management;
USA = United States of America; NM = not mentioned).
Authors Country/Year N Study
Period
(months)
Average PNI
pts/month
Average
Age (yrs)
Gender
(men %)
SW
(%)
GSW
(%)
NOM
(%)
Needed
Surgery (%)
Negative
Explorations (%)
Mortality
(%)
International Studies
Narrod & Moore [16] USA 1984 77 120 0.6 32 77 66 29 38 62 15 0
Demetriades et al [10] USA 1997 223 20 11.1 29 89 40 47 83 17 1 2.7
Prichayudh et al [9] Thailand 2015 86 120 0.7 27 90 74 19 52 48 4 2
Teixiera et al [17] Brazil 2016 161 60 2.7 26 88 82 18 60 40 0 1.9
de Régloix et al [7] France 2016 55 24 2.3 32 84 57 16 58 42 NM 11
Kasbekar et al [8] England 2017 63 72 0.9 33 NM 52 NM 65 35 77 NM
Ibraheem et al [11] USA 2018 337 96 3.5 30 81 62 31 65 35 13 4.5
Hundersmarck et al [19] Netherlands 2019 43 108 0.4 40 79 53 5 47 53 29 7
South African Studies
McQuaide & Villet [18] 1969 266 48 5.5 26 90 99 1 46 54 22 3.4
Campbell & Robbs [12] 1980 108 7 15.4 29 89 98 2 76 24 0 2.8
Ngakane et al [20] 1990 109 36 3.0 30 87 83 11.0 97 3 0 1.8
Apffelstaedt &Müller [13] 1994 393 21 18.7 30 NM 100 0 0 100 58 0
Thoma et al [14] 2008 203 13 15.6 29 91 78 21 12 88 0 0
Madsen et al [15] 2015 510 46 11.1 29 89 89 11 79 21 0.3 2
Madsen et al [21] 2018 817 72 11.3 28 88 87 13 NM NM NM NM
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MANAGEMENT STRATEGIES IN PENETRATING NECK INJURIES
The optimal management of PNIs remains controversial. The initial strategy of observing these
patients (as before World War I), led to unacceptably high mortality rates. Fogelman & Stewart [5]
recognised that many seemingly asymptomatic patients have serious underlying injuries and coupled
with the recognition that most neck explorations are associated with low morbidity rates, the emphasis
shifted towards exploring all wounds that breach the platysma muscle. However, this led to high rates
of negative and unnecessary neck explorations, prompting the notion that perhaps a more selective
process is required [5]. Apffelstaedt & Müller [13] showed a very high 58 % negative exploration rate
in their case series of 393 patients, who were all managed by mandatory neck exploration. Despite
their argument that mandatory exploration decreases missed injuries and reduces mortality and
morbidity, this must be balanced against unnecessary operations leading to increased healthcare costs
and iatrogenic injuries. The question is thus to find an optimum management strategy without
compromising patient outcomes.
In an attempt to address this question, the “neck zone” approach was developed. Monson et al in 1969
[22], initially described three zones of the neck. Since this initial “neck zone” description, some
modifications have taken effect and the current described borders of the neck zones pertain to the
anterior neck triangle only (i.e. anterior to the posterior border of the sternocleidomastoid muscle).
Zone I extends from the jugular notch to the cricoid cartilage, Zone II from the cricoid cartilage to the
angle of the mandible and Zone III from the angle of the mandible to the mastoid process [6].
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Figure 1. Anatomical zones for penetrating neck injury (taken from Von Waes et al. Management of penetrating
neck injuries [23])
The importance of this distinction lies in the fact that these zones were suggested to correlate with
underlying vascular and aerodigestive structures of importance and thus external injury was proposed
to predict internal injuries. Furthermore, they also affect surgical access, as Zones I and III are
certainly much more difficult to access. Zone I includes the thoracic inlet and surgical access often
requires median sternotomy, while Zone III is often treated more like a potential head injury and thus
may require craniotomy, or temporomandibular joint dislocation/subluxation for high internal carotid
artery exposure [3]. Zone II is much more readily accessible, usually via an anterior
sternocleidomastoid incision [3]. This led to the suggestion that injuries in Zone I and III should be
appropriately investigated first, while all Zone II injuries should be surgically explored [24]. This
approach has limitations, with a high negative exploratory rate for Zone II neck injuries, thus a
selective approach for these injuries was also suggested.
Many authors now believe the “neck zone” approach is clinically irrelevant and advocate for a “no
zone” approach [24, 25]. Low et al [25] showed a high rate of non-correlation between external
wounds in a specific zone and major internal injuries. With the “no zone” approach the
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haemodynamic status of the patient, and the use of clinical examination and appropriate
investigations, are used to guide whether operative intervention is indeed necessary, rather than the
site of the external injury [24].
Clinical signs of vascular and aerodigestive tract injuries are categorised into “hard” and “soft” signs,
with “hard” signs suggesting overt evidence of major injury. Hard signs of vascular injury include:
severe/uncontrolled haemorrhage, haemodynamic instability (shock not responding to fluid
resuscitation), expanding/pulsatile haematoma, bruit/thrill, absent/diminished distal pulses or
neurologic deficit (indicating cerebral ischaemia) [6, 26]. Less overt or “soft” signs of major injury
include: proximity injury, mild hypotension or history of hypotension (responds to resuscitation),
minor haemorrhage, haemoptysis/haematemesis, simple haematoma (not pulsatile/expanding and no
bruit/thrill), dysphagia/odynophagia, dysphonia, subcutaneous or mediastinal air [26].
Hard Signs Soft Signs
Vascular Bleeding: severe or uncontrolled
Haemodynamic instability (not responding to
resuscitation)
Haematoma: expanding or pulsatile
Bruit or thrill
Absent distal pulse (radial pulse)
Central neurologic fallout
Proximity injury
Bleeding: minor
Hypotension responding to fluid
Haematoma: non-pulsatile, non-expanding
Aerodigestive Air bubbling through the wound
Massive haemoptysis or haematemesis
Airway compromise or respiratory distress
Dysphonia
Dysphagia/odynophagia
Subcutaneous/prevertebral/mediastinal air
Haemoptysis/haematemesis: minor
Table 2. Hard and soft signs of vascular and aerodigestive tract injuries
The accuracy of these clinical signs to predict the presence of a major vascular injury and to
determine the need for operative intervention has also been queried. Data from the 1994 study by
Apffelstaedt & Müller [13], highlighted that clinically asymptomatic patients may harbour major
injuries and conversely, the presence of hard signs may not be associated with a major injury. They
showed that 30% of patients with no major clinical signs had positive findings intra-operatively, while
a significant proportion of patients with hard signs had a negative neck exploration (this included
shock, active bleeding, haematoma, surgical emphysema, dysphagia, and a blowing wound) [13].
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However, more recent consensus suggests that a thorough systemic enquiry and clinical examination
to be 95% accurate in identifying major vascular or aerodigestive tract injuries that require operative
intervention [5, 26]. It is evident that most surgeons would not argue with the notion that any patient
with a PNI with ongoing, uncontrolled external bleeding and haemodynamic compromise, or an
obvious major airway injury, is not a candidate for ancillary investigations and should be expedited to
the operating theatre.
INVESTIGATIONS FOR PNI
The Eastern Association for the Surgery of Trauma (EAST) guidelines on PNI [5] stipulate that
“given the potential morbidity of missed injuries, clinicians should have a low threshold for obtaining
imaging studies” [5]. As the notion of selective non-operative management of these injuries with the
selective use of diagnostic modalities became readily accepted, the ideal investigation of choice for
identifying vascular injuries was unclear. These included arteriography (i.e. catheter-directed
angiography) to exclude arterial injury and endoscopy (oesophagoscopy and laryngoscopy) or
oesophageal contrast study (oesophagogram) for suspected aerodigestive tract injuries [26]. Other
investigations available include duplex doppler and computerised tomographic angiography (CTA), of
which CTA has received a lot of attention more recently. With the increasing availability, relative
ease of use, and rapidly advancing technology with high sensitivity, specificity and accuracy, CTA
has become the investigation of choice in many centres. Its main use comes in identifying major
vascular injuries requiring intervention, but it also has a role in diagnosing aerodigestive tract injuries.
Although these injuries are less reliably diagnosed with CT, evidence of a stab or gunshot tract
running distant to the aerodigestive tract organs has been shown to decrease the need for further
investigations such as endoscopy or oesophageal contrast studies [27].
However, it is important to also realise that CT angiography has associated risks, including ionizing
radiation and contrast-related adverse events, and that it is not an infallible investigation, with some
studies showing less-than-desirable accuracy rates for the detection of vascular injuries. Bodanapally
et al [28] reviewed 53 CT scans of patients with PNI and compared this to digital subtraction
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angiography (DSA), which they considered to be the gold-standard investigation. CT scanners used
for this study Although they found a specificity of 96.4 % - 98.4 % for the detection of arterial injuries
in general, sensitivity for the detection of external carotid artery injuries specifically was much lower
at 63.4 % - 70.0 %, indicating that CT angiography missed about one third of external carotid artery
injuries. The authors conclude that negative findings on CT angiography should not preclude close
clinical follow-up and that if doubt exists DSA should be performed [28]. Importantly, this 2015 study
made use of 40 and 64-slice multidetector CT angiography, which may be considered outdated in
some modern centres. Other studies suggest much better CTA accuracy rates, with 100% sensitivity in
arterial injury diagnosis [29].
The EAST guidelines on PNI [5] highlight similar points and suggest that either CT angiography or
Duplex Doppler can be used to assess for vascular injuries. Concern with CT angiography is that
intimal injuries are often missed, while Duplex Doppler is a better imaging modality to identify
intimal tears [5]. Duplex Doppler is less invasive and in skilled hands has high accuracy rates [29],
however the concern of inter-user variability questions the consistency of the accuracy rates of this
imaging modality (Table 3), and is thus rarely used ahead of CT angiography. Furthermore, magnetic
resonance angiography (MRA) is reported as an imaging modality for PNI, but is also rarely used,
because of issues of availability, length of time to do the investigation, cost and significant
interference from movement and metallic streak artefact [29].
Imaging Modality Advantages Disadvantages Sensitivity Specificity
Catheter-directed
Angiography (CDA)
- Considered the “gold
standard”
- Most accurate – used as
comparative modality to
measure accuracy
- Invasive
- Risk of arterial puncture
site injury
- Ionizing radiation
- IV contrast
N/A N/A
Computed
Tomography
Angiography (CTA)
- More accessible than CDA
- Less invasive than CDA
- Ionizing Radiation
- IV contrast
75.7%–100% 93.5%-98.4%
Duplex Doppler - Non-invasive
- No radiation
- High accuracy for intimal
injury compared to CTA
- High inter-user
variability
91%-100% 85%-100%
Table 3. Comparison of vascular imaging modalities for PNI. (N/A = not applicable) [28,29]
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MANAGEMENT OF VASCULAR INJURIES
As with any trauma, managing patients with PNI begins with a primary survey according to Advanced
Trauma Life Support® (ATLS) principles [30]. Managing the airway in penetrating neck trauma can
be difficult and bleeding too, can be troublesome. Occlusion of the airway can occur because of direct
injury to the larynx or trachea, expanding haematoma in the neck, or can occur due to bleeding or
aspiration of blood into the airway. Injury to the pleura is possible from a neck wound as the apex of
the lung extends above the clavicle. This can lead to haemo- or pneumothoraces, which impair
ventilation but when severe (i.e. tension pneumothorax) can lead to haemodynamic instability
unrelated to bleeding. Massive external bleeding from sources in the base of skull, neck or thoracic
inlet is usually evident, but less evident internal bleeding may occur into the oropharynx or the pleural
space. A threatened or at-risk airway is secured with endotracheal intubation. Oral intubation is
attempted first, but in patients with distorted anatomy from direct injury or airway deviation from a
haematoma, a surgical cricothyroidotomy may be needed [30].
Foley Catheter Balloon Tamponade (FCBT)
Active bleeding from a neck wound can present a particular challenge to the healthcare provider.
Bleeding from a deep tract in the neck can be difficult to control with packing or direct digital
pressure and ongoing uncontrollable bleeding from the neck mandates emergent surgical intervention.
One technique that is present in the arsenal of clinicians at most levels of healthcare is the use of a
Foley catheter and inflation of the balloon to create a tamponade effect [32, 33]. Catheter balloon
tamponade is a useful and versatile technique, and although initially described for treating bleeding
oesophageal varices, it is now used in many clinical scenarios where inaccessible life-threatening
haemorrhage poses a challenge [32]. In the trauma setting, balloon tamponade is used, amongst
others, for penetrating cardiac injuries, major inaccessible limb vascular injuries and blunt intra-
abdominal solid organ injuries [32]. Data on its use in penetrating neck injuries is limited in the
current literature. Gilroy et al [34] first described the technique in their 1992 case series from
Baragwanath Hospital. This included 8 patients with major haemorrhage from penetrating neck
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injuries who had balloon tamponade with a Foley’s catheter employed to stop bleeding. In four of
these patients (50%) bleeding was completely arrested.
In 2006, Navsaria et al [33] published a larger series of 18 patients from Groote Schuur Hospital
(GSH). In this series the technique proved much more effective with 17 of the 18 patients having their
bleeding successfully stopped. The authors describe balloon tamponade as a useful resuscitative
technique, thus allowing further diagnostic imaging in these now-stabilised patients. Weppner [35]
went a step further and compared the use of catheter balloon tamponade to direct external pressure for
both penetrating neck and maxillofacial trauma in the military setting. He retrospectively compared
42 patients who had catheter balloon tamponade versus 35 who had only external pressure applied (in
these instances a Foley catheter was simply not available). This retrospective analysis revealed a
statistically significant difference in mortality between the two groups in favour of the Foley catheter
group (5% versus 23%) [35].
The only randomised controlled trial comparing catheter balloon tamponade to direct pressure is a
cadaver-based study by McKee et al [36]. This study compared the use of direct pressure, FCBT and
the use of the iTClamp (a commercial device to arrest bleeding) in 3 separate cadavers with simulated
penetrating neck injuries. The study showed that both FCBT and iTClamp were associated with
significantly less fluid loss (the primary outcome measure used as a surrogate for blood loss)
compared to direct manual pressure. The authors conclude that FCBT and the iTClamp were equally
effective but more effective than simple direct manual pressure [36]. The iTClamp was though both
easier and quicker to apply than a Foley catheter.
Series of PNI that included data on FCBT are tabulated in Table 4. These highlight how uncommonly
the technique is used, but also the paucity of data on FCBT in the current literature. The study by
Weppner [35] represents somewhat of an outlier as the rate of FCBT used was significantly higher
than in any other study (27.1%). This is perhaps explained by the fact that this study comes from the
military setting where the austere environment commonly forces the use of temporising measures
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such as FCBT and the much higher rate of high-velocity projectiles, compared to the low-velocity
injuries in the civilian setting. Of note also is the high rate of bleeding on catheter removal noted in
the Madsen et al [20] study. In all 8 cases (72.7%) where rebleeding was noted, the catheter was
removed soon after insertion (ranging from 0.5 – 28 hours), unlike the longer 48-hour time period
recommended by Navsaria et al [33].
Study Military (M)
/Civilian(C)
Total PNI
patients
% Needing
FCBT
FCBT Initial
Success Rate %
Bleeding on Catheter
Removal
Gilroy et al (1992) [34] C 56 8 (14.3%) 4/8 (50%) NM
Navsaria et al (2006) [33] C 220 18 (8.2%) 17/18 (94.4%) 1/14 (7.1%)
Weppner (2013) [35] M 155 42 (27.1%) 40/42 (95.2%) NM
Teixiera et al (2016) [17] C 161 1 (0.6%) 1/1 (100%) NM
Madsen et al (2018) [21] C 817 11 (1.3%) 8/11 (72.7%) 8/11 (72.7%)
Table 4. Comparison of recent PNI reports that include FCBT. NM = not mentioned.
The usual technique of Foley catheter tamponade involves the insertion of an 18-20 Fr Foley catheter
into the actively bleeding neck wound. This is done gently, without causing iatrogenic injury or
creating new tracts [31]. The catheter bulb is inflated with water until resistance is felt and the
catheter is clamped or knotted on itself [31] (Figure 2). The neck wound around the catheter is
sutured to prevent expulsion of the balloon. More than one catheter may be required to arrest the
haemorrhage. If the technique fails to control the bleeding, the patient is expedited to theatre for
surgical exploration. If, however, the technique is successful and bleeding has stopped, mandatory CT
angiography is performed. If this confirms an arterial injury, definitive management is undertaken via
endovascular or open surgical techniques [31]. If a venous injury or no vascular injury is seen on CT
angiography, the patient is admitted to the ward for serial neck examinations [31]. After 48 hours the
catheter is deflated in theatre and if no bleeding occurs after 5 minutes it is removed. If bleeding
occurs, formal surgical exploration is warranted [31].
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FCBT may have significant implications in those patients presenting with “hard signs” of vascular
injury who actually have relatively minor injuries and thus avoid the need for surgical neck
exploration. It can be used at all levels of care, including the pre-hospital setting, where it may help to
control or slow-down bleeding during transport and may have potential use in mass casualty
situations. The technique of using a Foley catheter balloon to stop bleeding from a penetrating neck
wound is thus described as easy-to-use, with readily-accessible equipment, and effective with a
success rate of >90% [33]. The current Groote Schuur Hospital departmental management algorithm
for using FCBT in PNI is outlined below [31].
Figure 2. Technique of Foley catheter insertion for penetrating neck injury
(taken from Von Waes et al. Management of penetrating neck injuries [23])
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Figure 3 – Algorithm for Foley catheter balloon tamponade in penetrating neck injury [31].
CT = computerised tomography, FC = Foley catheter, OR = operating room. Ancillary tests: water-
soluble contrast, panendoscopy.
Foley catheter into bleeding neck wound
Successful
CT angiography
Ancillary tests
CT angiography (-)
Ancillary tests (-)
Observe 48 hours
Remove FC in OR
Successful
Observe 24 hrs and discharge
Unsuccessful
Surgery
CT angiography (+)
& / or
Ancillary test (+)
Surgery
Unsuccessful
Surgery
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Definitive Management of Vascular Injuries
Penetrating neck injuries resulting in major arterial injuries are associated with significant morbidity
and mortality [37]. In fact, untreated carotid artery injuries have an associated mortality rate
approaching 100% [37]. Of the multiple vessels at risk from a penetrating neck injury, the carotid
arteries are the most commonly injured and reported [37 – 39]. Patients with penetrating carotid
injuries will present with a range of clinical signs, from active external bleeding with haemodynamic
instability to the occult carotid injury with no clinical signs at all [34]. Most authors will advocate that
any injury found either intra-operatively or on pre-operative imaging should be repaired [39]. Choices
for repair of the injured carotid artery include primary repair (arteriorrhaphy or end-to-end
anastomosis) or the use of a conduit such as the great saphenous vein (either as a patch or in-
continuity) or prosthetic grafts [38]. Some authors suggest that minor penetrating injuries, such as
small pseudoaneurysms or dissections can be managed as for blunt carotid injuries, which often
require antithrombotic therapy and follow-up with no surgical intervention needed [37, 38]. However,
due to the concerns that minor injuries can progress to large pseudoaneurysm formation or
thromboembolic events, non-operative management of penetrating carotid artery injuries remains
controversial.
Perhaps the biggest controversy exists around the question of repair versus ligation of carotid injuries.
Management of external carotid artery injuries is less controversial and most authors treat these
injuries by ligation [33, 35], but most case series reveal significant neurological sequelae of
common/internal carotid artery ligation. In most instances surgical repair is warranted. The
controversy lies in patients with carotid injuries who present with already-established central
neurological defects. In the past the main concern with re-establishing blood flow through the carotid
artery in this setting, is that outcomes can be significantly worsened due to conversion to cerebral
haemorrhage. However, large autopsy series looking at this have shown that haemorrhagic strokes
represent the minority of mortality cases and that cerebral oedema is the much more prevalent cause
of death [39]. In their case series of 32 patients with penetrating carotid artery injuries, Navsaria et al
[39], chose to ligate common or internal carotid injuries in patients with proven cerebral infarction or
25
oedema on CT brain, presence of prolonged coma, absence of backflow at surgery, arterial occlusion
on angiography or in high internal carotid artery injuries which are technically difficult to repair.
Importantly, although presence of coma is often considered a contraindication to carotid
revascularisation, Navsaria et al on review of the literature highlight the fact that patients presenting
soon after injury may have other causes for a reduced level of consciousness and thus carotid repair
with reconstitution of blood flow may represent the best way to improve outcome for these patients
[39].
The use of temporary vascular shunts to treat these injuries is also somewhat controversial. There
seems to be little evidence to support its use. Reva et al [40], showed that in their case series of 47
patients, mortality and neurological sequelae were not decreased by using a temporary vascular shunt,
which was used in a total of 8 patients and thus do not advocate for its use.
Endovascular management of vascular injuries seems to be gaining popularity and this is also true of
penetrating neck injuries [41]. Proposed advantages over open procedures include its use in vessels
that are technically difficult to access with open surgery (thus avoiding median sternotomy or
mandibular dislocation), the ability to perform the procedure under local anaesthesia thus allowing for
neurological monitoring during the procedure, and in some centres endovascular techniques are used
as adjuncts to open surgery – a hybrid approach where proximal control is achieved by endovascular
techniques [41]. Arteries that are considered especially difficult to access through open surgery
include the subclavian artery, the vertebral artery, the proximal common carotid artery and the distal
internal carotid artery.
Subclavian artery injuries, especially pseudoaneurysms, are amenable to endovascular repair. In their
Western Trauma Association multicentre review, Waller et al [42], showed that 22% of patients with
subclavian artery injuries were definitively managed by endovascular techniques. Naidoo et al [43],
published a large case series from Groote Schuur Hospital of 31 patients with penetrating subclavian
or axillary artery injuries that were managed with endovascular stent-graft placement. They showed
26
an 84% primary technical success rate with a 90% overall stent-graft patency rate. This study
highlights the efficacy and safety of endovascular management of subclavian arterial injuries in well
selected patients [43].
Endovascular management of carotid artery injuries is now also gaining popularity, with multiple case
reports and series emerging in the literature. One of the largest series comes from South Africa. In
their series of 19 patients from Tygerberg Hospital with penetrating carotid artery injuries managed
endovascularly, Du Toit et al [44], highlight the success of the technique. Their patient selection
included mainly those patients representing difficult access injuries, notably proximal common
carotid and distal internal carotid artery injuries. In this series of well-selected cases, technical success
was 100% and outcomes showed only one death in the group (due to cerebral oedema) and one stroke.
The authors go on to advocate the use of endovascular management of these injuries [44].
Conclusion
Penetrating neck injuries remain an important clinical entity in trauma. Vascular injuries represent the
most life-threatening initial concern after the airway has been secured and management of these
important injuries is constantly evolving. Selective non-operative management is now considered
standard of care in most institutions. Increasing use of CT angiography is reducing the need for formal
diagnostic angiography, but conversely interventional endovascular techniques seem to be gaining
popularity. Simple techniques like Foley catheter balloon tamponade can help stabilise patients to
allow for further investigation and direct management decisions, however data on the use of balloon
tamponade for bleeding neck injuries is limited and further research is needed in this field.
27
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31
PUBLICATION READY MANUSCRIPT
INTRODUCTION
The use of a Foley catheter balloon to tamponade a penetrating neck wound is a well-recognised
strategy used to temporarily arrest catastrophic bleeding. We reported our experience with this
technique in 2006 and proposed an institutional management algorithm [1]. Since then civilian reports
of the success of this life-saving procedure have been few, thus underscoring its infrequent need
(Table 1). As a follow-up we now report on a larger cohort of patients managed with Foley catheter
balloon tamponade (FCBT) for penetrating neck injuries and attempt to validate the previously
proposed algorithm.
METHODS
The trauma unit at Groote Schuur Hospital (GSH) is a level one urban trauma centre with a high
incidence of penetrating trauma. The protocol for the treatment of penetrating neck injuries is one of
selective nonoperative management. For the period of December 2015 to September 2017 (22
months) adult patients presenting with a penetrating neck injury in whom FCBT was used to arrest
haemorrhage, were retrospectively identified from an established prospective penetrating neck injury
database. Data included patient demographics, mechanism of injury, admission vital signs, neck zone
injured, investigations, management and major outcomes. Injury severity was categorised according
to the Revised Trauma Score (RTS), Injury Severity Score (ISS), Trauma and Injury Severity Score
(TRISS) and New Injury Severity Score (NISS). Specific data on the use of FCBT included the
designation of the facility (level of care) at which the catheter was placed, the number of catheters
deployed in each patient and the success rate at arresting haemorrhage. Visceral and vascular injuries
were identified either at surgery and/or on computerised tomography angiography (CTA) and/or
ancillary tests. Complications related to the insertion of the catheter or its removal were documented.
Basic descriptive statistical analysis was performed using functions available in Microsoft Excel©.
32
This study had full ethics approval from the University of Cape Town Human Research Ethics
Committee (HREC) and institutional approval from Groote Schuur Hospital.
Patients presenting with bleeding penetrating neck injuries were resuscitated along Advanced Trauma
Life Support (ATLS) guidelines and managed as per the Groote Schuur Hospital institutional
algorithm for the use of FCBT for bleeding neck injuries (Figure 1).
An 18G or 20G Foley catheter (FC) was placed into the penetrating neck wound and along the injury
tract. The balloon of the catheter was inflated until resistance was felt and the catheter was then either
knotted on itself or clamped to stop back-bleeding. More than one catheter could be utilised (Figure
2). The neck wound was sutured around the catheter to prevent expulsion. Failed FCBT was an
indication to proceed to emergent surgery. Patients in whom haemorrhage was successfully stopped
using FCBT underwent CTA and further ancillary tests as indicated. This included formal catheter-
directed angiography for equivocal CTA findings or for endovascular intervention, gastrointestinal
endoscopy and/or contrasted swallow examination for suspected pharyngo-oesophageal injuries.
Patients were monitored in a high-care unit with close monitoring and neck observations. After 48
hours, removal of the FC was attempted in the operating room. Anaesthesia and operating room staff
were available to proceed to surgery in the event of bleeding. The balloon was deflated, and after 5
minutes, the catheter was slowly withdrawn. Bleeding at any stage of the procedure warranted
induction of general anaesthesia and neck exploration. After successful removal of the catheter, the
wound was irrigated, cleaned and closed with interrupted non-absorbable sutures and the patient
discharged after a further 24-hour observation period.
33
RESULTS
Over the 22-month study period a total of 628 patients presented to GSH with a PNI (average of 28.5
PNI patients/month), of which 95 patients (15.2%) required the use of FCBT. In the remaining 533
patients who did not require FCBT, only 6 (0.96%) were expedited directly to theatre without
appropriate imaging first. The remaining 527 were admitted and either observed clinically without
further imaging (147 patients) or underwent further imaging (380 patients).
Of the cohort of 95 FCBT patients, 93 were men (97.9%) with an average age of 27.9 years (+/- 7.8
years, range of 18 – 48 years, interquartile range [IQR] 22 – 32 years). The mechanism of injury was
predominantly stabbings (86 patients [90.5%]), while 9 patients (9.5%) sustained low-velocity
gunshot wounds to the neck. In the cohort of all 628 PNI patients the mechanism of injury included
484 (77.1%) stabbings (this included mainly knife stabbings, but also screwdrivers and broken glass),
111 (17.7%) gunshot wounds, and 33 (5.3%) other or unknown mechanism of injury (including 4
cases of axe/machete injuries, 2 dog bites, impalement on an iron fencepole, use of a garden spade,
and an angle grinder injury).
Zone II was the most commonly injured neck zone (34.7%), 11.6% of patients were hypotensive
(systolic blood pressure < 90mmHg) and 15.8% had a Glasgow Coma Score of less than 8 on arrival.
The average Injury Severity Score (ISS) on admission was 11.14 with 26.3% of patients having an
ISS >15 on admission (Table 2).
FCBT Details
Details of the level of care where these catheters were placed, the number of catheters that were
needed in each patient and the problems associated with the use of FCBT are outlined in Tables 3 and
4. Almost half of these catheters were inserted either in the prehospital or clinic level. In almost all
patients one or two catheters were sufficient to arrest haemorrhage, although 2 patients required more
than 2 catheters to achieve haemostatic control. There were some instances where catheters fell out
34
en-route to our centre either by accidental removal or the balloon not being inflated. In one instance,
the catheter was noted to lie too shallow in the injury tract with ongoing bleeding. The bleeding was
successfully aborted with removal of the in-situ catheter and replacement with another catheter placed
deeper into the tract. Of the 95 patients, bleeding was successfully arrested in 92 patients (96.8%).
Only three patients (3.2%) had ongoing bleeding despite the correct placement of the Foley
catheter(s). One of these patients demised in the trauma resuscitation room due to advanced shock and
the other two were successfully expedited to theatre. One of these patients had a subclavian vein
injury while the other had injuries to the thyrocervical trunk, anterior and internal jugular veins. Two
patients had bleeding at the time of catheter removal in theatre (see below).
Investigations
Of the total 95 patients, 88 (92.6%) had computerised tomography angiography (CTA) performed,
while the remaining 7 patients who did not have a CTA included 2 patients who were expedited
directly to theatre with ongoing active bleeding, 2 patients who died in the trauma resuscitation room
shortly after arrival and 3 patients where the catheter had been accidentally dislodged and had no
further major vascular signs and were thus successfully clinically observed. Only 8 patients (8.4%)
required formal digital subtraction angiography, of which 2 were purely diagnostic for equivocal CTA
findings and the remaining 6 required endovascular intervention (Figure 3). A total of 32 patients
(33.7%) with suspicion of concomitant aerodigestive tract injuries were investigated with a water-
soluble contrast swallow study and 9 patients (9.5%) went on to have some form of aerodigestive tract
endoscopy (laryngopharyngoscopy, oesophagoscopy or bronchoscopy).
Confirmed Vascular Injuries
A total of 29 patients (30.5%) had an arterial injury, which included a total of 19 major arteries in 15
patients and a further 15 minor arterial injuries (one of these patients had both a major and minor
arterial injury). In 23 patients, a total of 26 separate venous injuries were confirmed on CTA or intra-
operatively. Twelve patients (12.6%) had both arterial and venous injuries. Importantly, a further 18
patients had visible abnormalities in the major neck veins on the venous phase of the CTA, of which 3
35
were reported to be likely artefactual or due to phasing issues, while the remaining 15 where reported
as possible venous injuries. Seven aerodigestive tract injuries were observed in this cohort, including
1 tracheal injury and 6 pharyngeal injuries. Figure 4 shows a breakdown of patients with arterial and
venous injuries and Table 5 shows specific arterial and venous injuries.
Management
A total of 27 patients (28.4%) had airway compromise after their initial injury, of which 25 patients
(26.3%) were successfully managed with oral endotracheal intubation while the other 2 patients
(2.1%) required surgical cricothyroidotomy. Blood transfusion was needed in 27 patients (28.4%) and
4 of these patients met the criteria for massive blood transfusion. A total of 13 patients underwent
surgical neck exploration for vascular injuries. Procedures performed included 9 arterial repairs (6
arteries repaired primarily, 2 repairs with venous grafts and 1 with synthetic graft), and 3 arterial
injuries managed with ligation of the artery (vertebral artery, external carotid artery and thyrocervical
trunk). Six patients were managed with endovascular techniques, including endovascular stenting of 4
subclavian artery injuries (all subclavian artery injuries in this study were managed endovascularly)
and endovascular coiling of pseudoaneurysms of the vertebral artery and thyrocervical trunk. Of the
total 26 documented venous injuries, 9 were managed operatively with 2 primary repairs (both
internal jugular veins) and ligation of a further 7 venous injuries. In 8 of these injuries a concomitant
arterial or aerodigestive tract injury was found and surgically managed, while only one patient had an
isolated venous injury needing surgery. The remaining 17 confirmed venous injuries were
successfully managed without the need for vascular operative intervention.
Removal of the Foley’s catheter was performed during the initial vascular procedure in these 13
patients needing surgical exploration, while a further 72 patients had their Foley catheter(s) removed
in the operating room as a separate, delayed procedure at 48 hours post injury. In 70 of these 72
patients (97.2%) no bleeding was encountered on removal of the catheter while 2 patients had
bleeding noted from the wound. One of these patients had a superficial venous branch of the external
jugular vein identified as the source of the bleeding, which was ligated. The other patient had venous
36
bleeding from deep within the wound and injury from the subclavian vein was thought to be the
source. Due to difficult surgical access, the decision was made to re-insert the Foleys catheter and re-
inflate the balloon. This successfully stopped the bleeding and the catheter was then successfully
removed without any further bleeding 48 hours later. In 10 patients the catheter was not removed in
theatre has it had either been accidentally dislodged or the patient died (n = 4) with the catheter still
in-situ.
Outcomes
The median length of hospital stay for the patient cohort was 4 days (+/- 12.6 days, range <1 day to
116 days, IQR: 2 – 6 days). This was skewed by numerous patients requiring prolonged
hospitalisation for multiple other injuries. One patient suffered a cervical spinal cord injury with
quadriplegia and ultimately spent 116 days in hospital. A total of 15 patients (15.8%) required
admission to the intensive care unit. Twenty-eight patients (29.5%) had a total of 36 separate
morbidities which are listed in Table 6. In the 4 patients suffering cardiac arrest where
cardiopulmonary resuscitation was attempted, two patients ultimately survived and two demised.
There were 4 deaths equating to a mortality rate of 4.2% in this cohort. One of these patients had
evidence of raised intracranial pressure from a large middle cerebral artery territory infarct from a
common carotid injury, had no ongoing haemorrhage from the neck wound and was deemed
neurologically unsalvageable on arrival. The second patient sustained gunshot wounds to both the
neck and head (transcranial) and was essentially braindead on arrival (this mortality was attributed to
the head injury and not the neck injury). The third mortality was a delayed referral, initially managed
at a secondary hospital. The patient was well on initial presentation, but re-presented to the hospital a
week post injury with renewed bleeding from the neck wound (prompting FCBT), focal neurological
signs and systemic sepsis. Imaging revealed missed common carotid artery and vertebral artery
injuries and features of cerebral infarction, which prompted referral to GSH. At GSH no further
bleeding was noted, but the patient demised shortly after arrival despite resuscitation efforts. The
cause of death was deemed a combination of sepsis and cerebral infarction and not from
exsanguinating haemorrhage. The last patient had a history of active bleeding at the referral clinic
37
which was controlled with pressure and skin closure (no FCBT used initially). Bleeding restarted en-
route in the ambulance and on arrival to GSH the patient was in extremis, with profound hypotension,
hypothermia, acidosis and coagulopathy. FCBT was attempted at GSH, but the patient demised
shortly after arrival.
38
DISCUSSION
There is limited data on the use and success rate of FCBT for PNI. Even less is known about the rate
of bleeding encountered when the catheters are removed. Gilroy et al [2] and Navsaria et al [1] both
highlight that venous injuries respond well to balloon tamponade for haemorrhage control and FCBT
may thus represent a form of definitive management in these patients. FCBT is superior to direct
digital pressure at stopping bleeding and may reduce mortality [3, 7]. When successful, the technique
allows patients to be resuscitated, stabilised, and appropriately imaged. Further management planning,
which may include immediate intervention or admission for observation followed by removal of the
catheter, can be instituted. When vascular intervention is required, open surgery can be planned in a
more controlled manner, with the further option of endovascular repair.
This series reports what we believe to be the largest patient cohort utilising FCBT in PNI and thus
allows for analysis of this simple, easy and accessible haemostatic technique. In this series of 628 PNI
patients, FCBT was attempted in 95 (15.2%) patients, achieving haemostasis with haemodynamic
stabilisation in 92 (96.8%) patients, illustrating its efficacy. With roll-out of our institutional
algorithm since our last report in 2006, there is an almost two-fold increase in the use of the technique
(8% vs 15%) [1].
Demographics in this cohort are similar to most case series on penetrating neck injuries from South
Africa and internationally, with the majority of patients being male with an average age under 30
years. The mechanism of injury was predominantly knife stabbings, with 9 patients with gunshot
wounds. Compared to the entire cohort of PNI patients, those patients where FCBT was used had
slightly less gunshot wounds.
Just under half of patients in this cohort had the catheter(s) inserted at either clinic or pre-hospital
level care. This further highlights the ease of access and simplicity of the technique, with success
possible even in the somewhat uncontrolled environment of the prehospital setting, such as in an
39
ambulance during transfer. Foley catheters are available in almost all healthcare settings and require
no special equipment or formal training to be successfully used to tamponade neck bleeding.
Although a single catheter suffices to control bleeding in most cases, if bleeding persists two or more
catheters may well be successful at arresting haemorrhage.
In our institution FCBT is an indication for specialised vascular imaging in the form of a CTA. A total
of 34 arterial injuries were identified in 29 patients (30.5%). Of these, 12 were managed with open
surgery and a further 6 were managed endovascularly (Figure 3). Thirteen minor arterial injuries seen
on CTA were managed with no further intervention. FCBT thus represents a form of definitive
management for these minor arterial injuries. A further three major arterial injuries were identified on
CTA in 2 patients (one patient with a common carotid artery injury only and one patient with both
common carotid and vertebral artery injuries), both of whom died from massive cerebral infarcts.
A total of 26 venous injuries were identified in 23 patients (24.2%). Of these, 9 were managed with
surgery. One required emergency surgery without preoperative imaging for continued bleeding from a
subclavian vein injury. A further 8 venous injuries were operatively managed with either repair or
ligation, but formed part of the surgery done for concomitant arterial or aerodigestive tract injuries. In
none of these 8 cases was the venous injury the primary indication for surgery. The remaining 14
patients did not require surgery for the confirmed venous injuries on CTA and were successfully
managed non-operatively. FCBT thus further represents a form of definitive management for these
venous injuries.
Patients with a negative CTA, or one that confirms a minor arterial or venous injury, and negative
ancillary tests, are observed for a period of 48 hours: the first 24 hours form part of the penetrating
neck injury protocol, where the patient is kept nil per mouth and observed for development of hard
signs of a vascular or aerodigestive tract injury; the next 24 hours the patient is fed and observed for
development of hard signs of a vascular or aerodigestive tract injury. The catheter is then removed
under controlled conditions in the operating room.
40
Foley catheters were removed in 72 patients after this period of observation. In two patients bleeding
was encountered either on deflation of the bulb or removal of the catheter. One patient was explored
and a small muscular venous vessel was ligated. In the other patient, the catheter was reinserted with
success. On review of the CTA intra-operatively a subclavian vein injury was suspected. It was
decided not to proceed with exploration. The catheter was successfully removed a further 48 hours
later. This rebleeding rate of 2.8% following removal of the catheter shows an improvement from the
previously reported 7% from our institution [1].
Madsen et al [5] report a rebleeding rate of >70% following catheter removal. In 8 of their 11 patients
who needed FCBT, the catheter was removed at 28 hours or less after insertion and in 5 patients the
catheters were removed within 10 hours. In only 3 patients was no bleeding encountered on removal
and in all three the catheter was kept in for longer than 24 hours. These findings thus support our
policy of waiting at least 48 hours before catheter removal is attempted.
41
CONCLUSION
This large series on FCBT for PNI highlights this technique in its simplicity and effectiveness at
controlling bleeding. Foley catheters are readily available at all levels of care. It allows for
stabilisation of seriously injured patients who can be appropriately imaged and managed in a more
planned and controlled manner. The technique can be used as a definitive form of management in
well-selected cases with venous or minor arterial injuries in the neck. However, it is prudent to wait
48 hours before catheter removal is attempted in those patients not requiring initial management of
major arterial injuries. We advocate for the role of FCBT in PNI because it is accessible, easy-to-use
and ultimately highly effective.
42
List of Tables
Table 1. Recent PNI reports that include FCBT
Table 2. Admission vital signs an injury severity scores in 95 patients
Table 3. Facility designation and number of catheters placed per patient.
Table 4. Foley Catheter Placement Complications
Table 5. Vascular injuries identified
Table 6. Overall Morbidities
Study Military (M)/
Civilian(C)
Total PNI
patients
% Needing
FCBT
FCBT Initial Success
Rate
Bleeding on Catheter
Removal
Gilroy et al (1992) [2] C 56 8 (14.3%) 4/8 (50%) NM
Navsaria et al (2006) [1] C 220 18 (8.2%) 17/18 (94.4%) 1/14 (7.1%)
Weppner (2013) [3] M 155 42 (27.1%) 40/42 (95.2%) NM
Teixiera et al (2016) [4] C 161 1 (0.6%) 1/1 (100%) NM
Madsen et al (2018) [5] C 817 11 (1.3%) 8/11 (72.7%) 8/11 (72.7%)
Table 1. Recent PNI reports that include FCBT. NM = not mentioned.
43
Admission Findings
Neck Zone Injured
- Zone I 21 (22.1%)
- Zone II 33 (34.7%)
- Zone III 10 (10.5%)
- Posterior 17 (17.9%)
- Multiple Zones 14 (14.7%)
Admission Systolic Blood Pressure
- < 90mmHg 11 (11.6%)
- > 90mmHg 84 (88.4%)
Admission Glasgow Coma Scale (GCS)
- GCS 15 67 (70.5%)
- GCS 13-14 3 (3.2%)
- GCS 8-12 10 (10.5%)
- GCS <8 15 (15.8%)
Admission Trauma Severity Scores
ISS
- ISS Average 11.14
- ISS < 10 56 (58.9%)
- ISS 10 – 15 14 (14.7%)
- ISS >15 25 (26.3%)
RTS
- RTS > 4 90 (94.7%)
- RTS < 4 5 (5.3%)
NISS
- Average NISS 12.21
- NISS < 10 52 (54.7%)
- NISS 10 – 15 16 16.8%)
- NISS > 15 27 (28.4%)
TRISS
- TRISS < 50% chance of survival: 7 (7.4%)
- TRISS 50 – 90% chance of survival: 10 (10.5%)
- TRISS 90 – 99% chance of survival: 23 (24.2%)
- TRISS >99% chance of survival: 55 (57.9%)
Table 2. Admission vital signs an injury severity scores in 95 patients. ISS = Injury Severity Score,
RTS = Revised Trauma Score, NISS = New Injury Severity Score, TRISS = Trauma and Injury
Severity Score.
44
Catheter Placement Number of Patients
Level of Care where Catheter was Placed
- Prehospital (Ambulance) 1 (1.1%)
- Primary Level (Clinic) 43 (45.3%)
- Secondary Level (District Hospital) 33 (34.7%)
- Tertiary Level (GSH) 18 (18.9%)
Number of Catheters Needed in Each Patient
- One catheter 80 (84.2%)
- Two catheters 13 (13.7%)
- Three catheters 1 (1.1%)
- Four catheters 1 (1.1%)
Table 3. Facility designation and number of catheters placed per patient.
Foley Catheter Placement Complications Number of Patients
Catheter fell out accidentally (none with subsequent bleeding) 5 (5.2%)
Ongoing bleeding despite correct FCBT 3 (3.2%)
Balloon not inflated/not inflated enough 3 (3.2%)
Catheter lying too shallow (with initial bleeding) 1 (1.1%)
Catheter inserted into wrong tract/wound 1 (1.1%)
Bleeding at time of catheter removal in theatre 2 (2.1%)
Table 4. Foley Catheter Placement Complications
Table 5. Vascular injuries identified
Major Arterial Injury No. Minor Arterial Injury No. Venous Injury No.
Common carotid artery 8 Thyrocervical trunk 4 Internal jugular vein 13
Internal carotid artery 1 Thyroid arteries 3 External jugular vein 4
External carotid artery 1 Lingual 2 Subclavian vein 2
Vertebral artery 3 Facial 1 Brachiocephalic vein 2
Subclavian artery 4 Suprascapular 1 Other/minor veins 5
Brachiocephalic artery 2 Other/unnamed vessels 4
Total 19 Total 15 Total 26
45
Specified Morbidity Number
Wound site infection 8
Cerebrovascular accident/Stroke 5
Pneumonia/Empyema 5
Massive blood transfusion 4
Cardiac arrest needing cardiopulmonary resuscitation 4
Missed injury (subclavian vein) 1
Prolonged pharyngeal leak/Pharyngocutaneous fistula 2
Other* 7
Table 6. Overall Morbidities (*Other [one each]: urinary tract infection, thrombophlebitis, sacral
decubitus ulcer, quadriplegia, chylothorax, infective diarrhoea [suspected C. difficile infection], limb
compartment syndrome [unrelated to PNI])
46
List of Figures
Figure 1. Algorithm for Foley catheter balloon tamponade in penetrating neck injury
Figure 2. Photograph of patient with left neck stab wound who required the insertion of 4 Foley
catheters to arrest active bleeding.
Figure 3. Successful FCBT for actively bleeding right-sided zone I neck stab with subclavian artery
injury.
Figure 4. Summary of Arterial and Venous Injuries
47
Figure 1. Algorithm for Foley catheter balloon tamponade in penetrating neck injury [6]. CT =
computerised tomography, FC = Foley catheter, OR = operating room. Ancillary tests: water-soluble
contrast, panendoscopy.
Foley catheter into bleeding neck wound
Successful
CT angiography
Ancillary tests
CT angiography (-)
Ancillary tests (-)
Observe 48 hours
Remove FC in OR
Successful
Observe 24 hrs and discharge
Unsuccessful
Surgery
CT angiography (+)
& / or
Ancillary test (+)
Surgery
Unsuccessful
Surgery
48
Figure 2. Image of patient with left zone I stab wound requiring the insertion of 4 Foley catheters to
arrest bleeding (courtesy of corresponding author).
49
Figure 3. Successful FCBT for bleeding right-sided zone I neck stab wound. a.) Coronal view of CTA
showing inflated Foley catheter balloon within stab tract (arrow) b.) Coronal view of CTA showing
subclavian artery pseudoaneurysm (arrow) c.) Digital subtraction angiogram (DSA) image confirming
right subclavian artery pseudoaneurysm (arrow) d.) DSA image post stent-graft placement showing
resolution of the pseudoaneurysm.
a b
c d
50
Figure 4. Summary of Arterial and Venous Injuries
Total:
95 FCBT Patients
Arterial Injuries (no venous injuries):
17 patients (17.9%)
Venous Injuries (no arterial injuries):
11 Patients (11.6%)
Combined Arterial and Venous Injuries:
12 Patients (12.6%)
Equivocal CTA Venous Findings:
15 Patients (15.8%)
No Vascular Injuries:
40 Patients (42.1%)
51
REFERENCES
1.) Navsaria P, Thoma M, Nicol A (2006) Foley Catheter Balloon Tamponade for Life-threatening
Hemorrhage in Penetrating Neck Trauma. World J Surg 30: 1265–1268
2.) Gilroy D, Lakhoo M, Charalambides D, Demetriades D (1992) Control of life-threatening
haemorrhage from the neck: a new indication for balloon tamponade. Injury 23(8):557
3.) Weppner J (2013) Improved mortality from penetrating neck and maxillofacial trauma using Foley
catheter balloon tamponade in combat. J Trauma Acute Care Surg 75(2):220-4
4.) Teixeira F, Menegozzo CAM, Netto SDDC, et al (2016) Safety in selective surgical exploration in
penetrating neck trauma. World J Emerg Surg 11:32
5.) Madsen AS, Bruce JL, Oosthuizen GV, et al (2018) The Selective Non-operative Management of
Penetrating Cervical Venous Trauma is Safe and Effective. World J Surg 42:3202-3209
6.) Navsaria PN. Chapter 4: Head and Neck Hemorrhage: What Do I Do Now? (2018) In: Treatment
of Ongoing Bleeding: The Art and Craft of Stopping Severe Bleeding. Springer International
Publishing, p. 45 – 54
7.) McKee JL, Mckee IA, Bouclin MD, et al (2019) A randomized controlled trial using iTClamp,
direct pressure, and balloon catheter tamponade to control neck haemorrhage in a perfused human
cadaver model. J of Emerg Med 56(4): 363-370
52
APPENDICES Appendix 1: Ethics Approval – University of Cape Town Human Research Ethics Committee
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Appendix 2: Intended Journal for Publication - World Journal of Surgery: Submission Instructions to
Authors.
54