Article

Delayed evaluation of combat-related penetrating neck trauma

Department of Surgery, Walter Reed National Military Medical Center, Washington, Washington, D.C., United States
Journal of Vascular Surgery (Impact Factor: 2.98). 08/2006; 44(1):86-93. DOI: 10.1016/j.jvs.2006.02.058
Source: PubMed

ABSTRACT The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States.
From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed.
Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1).
Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.

Full-text

Available from: Jason S Hawksworth, Jun 02, 2015
0 Followers
 · 
143 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.
    Craniomaxillofacial Trauma and Reconstruction 09/2014; 7(3):175-89. DOI:10.1055/s-0034-1372521
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Pseudoaneurysm formation following gunshot wounds is associated with significant morbidity. The natural history and optimal follow-up strategy for penetrating injuries causing dissection remains poorly understood. We report a case of a giant compressive pseudoaneurysm that developed following recanalization of an occlusive internal carotid artery dissection sustained from a gunshot wound. This was detected on routine follow-up imaging six weeks later. The patient subacutely developed dysphagia and hoarseness initially felt to be caused by delayed injury to the laryngeal nerve because computed tomography angiography demonstrated no new pathology. The pseudoaneurysm was successfully treated using a covered stent graft. This case highlights the importance of close angiographic follow-up even in the setting of initial complete vessel occlusion, and the need for a high suspicion for pseudoaneurysm development in the setting of new compressive or neurologic symptoms in patients with potential vascular injury from gunshot wounds to the neck.
    Injury Extra 09/2013; 44(9):75–78. DOI:10.1016/j.injury.2013.08.014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Después de presentar los datos epidemiológicos de las heridas cervicofaciales por proyectiles (cifras, poblaciones y forma de producción), en este artículo se describe su patogenia, precisando las nociones de balística útiles para el médico, así como las consecuencias fisiopatológicas. Se propondrá una tipología de la anatomía facial y cervical de las lesiones. En el apartado del análisis clínico se exponen los métodos clínicos, de imagen y de endoscopia que se emplean en estas lesiones. Este análisis permite individualizar los índices de gravedad vitales, funcionales y estéticos. El aspecto lesional se describe según las modalidades de la anatomía de las lesiones. Después, se recordarán los principios terapéuticos, adaptándolos a este tipo de lesiones traumáticas, así como los métodos médicos, con la aplicación de una antibioticoterapia precoz y tratamiento psiquiátrico, además de los métodos quirúrgicos con los medios mecánicos de lavado y de drenaje. El esquema terapéutico concluirá con la descripción de la intervención y su organización, tras lo que se detallará su desarrollo, individualizando las distintas fases de extrema urgencia, de urgencia, de tratamiento secundario y de la etapa de las secuelas, apoyándose en los índices de gravedad de las heridas cervicofaciales.
    01/2008; 37(4):1–12. DOI:10.1016/S1632-3475(08)70300-X