• Tisherman SA, Bokhari F, Collier B, Ebert J, Holevar M, Cumming J, Kurek S, Leon S, Rhee P. Clinical practice guidelines: penetrating neck trauma. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2008. 52 p. [126 references]

This is the current release of the guideline.

Penetrating wounds of the Zone II region of the neck that penetrate the platysma

Management
Treatment

Critical Care
Emergency Medicine
Pulmonary Medicine
Surgery
Thoracic Surgery

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

To answer the following questions regarding the management of penetrating injuries to Zone II of the neck that penetrate the platysma:

• Is operative management mandatory or is selective non-operative management appropriate?
• Is physical examination adequate to rule out injuries to vascular structures or the aerodigestive tract?
• Can duplex ultrasonography (US) or Computed tomography (CT) angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary?
• How should specific vascular injuries be managed?
• Are both contrast studies (barium or gastrograffin swallow) and esophagoscope needed to safely rule out esophageal injury?
• Is there a need for immobilization of the cervical spine?

Patients with penetrating neck trauma of the Zone II region

Diagnosis/Assessment

1. Selective operative management and mandatory exploration (of penetrating injuries to Zone II)
2. Diagnosis of arterial injury
   • Computed tomography (CT) angiography
   • Duplex ultrasonography
   • Arteriography
3. Diagnosis of esophageal injury
   • Contrast esophagography
   • Esophagoscopy
4. Physical exam including auscultation of the carotid arteries

Management

1. Management of specific vascular injuries
• Angiographic approaches to vertebral artery injuries
• Ligation of the jugular vein (for complex injuries or unstable patients)
2. Cervical spine immobilization in select patients

• Mortality
• Missed injury rates

Searches of Electronic Databases

145

Weighting According to a Rating Scheme (Scheme Given)

Class I: Prospective, randomized, double blinded study

Class II: Prospective, randomized, non-blinded trial

Class III: Retrospective series, meta-analysis

Systematic Review with Evidence Tables

An evidentiary table (see Table 1 in the original guideline document) was constructed using the 145 references that were identified: Class I, 2 references; Class II, 26 references; and Class III, 105 references. Twelve of the references could not be classified.

Expert Consensus

Recommendations were made on the basis of the studies included in the evidentiary table (see Table 1 of the original guideline document).

Level 1: Usually based on class I data, were meant to be convincingly justifiable on scientific evidence alone.

Level 2: Usually supported by class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion.

Level 3: Usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not stated

Not applicable

The levels of recommendation (1-3) and classes of evidence (I-III) are defined at the end of the "Major Recommendations" field.

1. Selective workup – operation vs. selective non-operative management

   Level 1

   Selective operative management and mandatory exploration of penetrating injuries to Zone II of the neck are equally justified and safe.

   Level 2

   No recommendations.

   Level 3

   No recommendations.

2. Diagnosis of arterial injury

   Level 1

   No recommendations.

   Level 2

   Computed tomography (CT) angiography or duplex ultrasonography can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to Zone II of the neck.

   Level 3

   CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed.

3. Diagnosis of esophageal injury

   Level 1

   No recommendations.

   Level 2

   Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours.

   Level 3

   No recommendations.

4. Value of the physical exam

   Level 1

   No recommendations.

   Level 2

   No recommendations.

   Level 3

   1. Careful physical examination, including auscultation of the carotid arteries, is >95% sensitive for detecting arterial injuries that require repair. Given the potential morbidity of missed injuries, imaging is still recommended.
   2. Physical examination is inadequate to rule out injuries to the aerodigestive tract.

5. Management of specific vascular injuries

   Level 1

   No recommendations.

   Level 2

   1. Except for minimal intimal irregularities or small pseudoaneurysms without neurologic deficits, penetrating injuries to the internal carotid artery should be repaired, even when severe neurologic deficits are present.
   2. Angiographic approaches to the vertebral artery are preferred to operative approaches for patients with bleeding from vertebral artery injuries.
   3. Ligation of the jugular vein is appropriate for complex injuries or unstable patients.

   Level 3

   No recommendations.

6. Cervical Spine Immobilization

   Level 1

   No recommendations.

   Level 2

   Immobilization of the cervical spine is unnecessary unless there is overt neurologic deficit or an adequate physical examination cannot be performed (e.g., the unconscious victim).

   Level 3

   No recommendations.

Definitions:

Classes of Evidence

Class I: Prospective, randomized, double blinded study

Class II: Prospective, randomized, non-blinded trial

Class III: Retrospective series, meta-analysis

Levels of Recommendation

Level 1: Usually based on class I data, were meant to be convincingly justifiable on scientific evidence alone.

Level 2: Usually supported by class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion.

Level 3: Usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate management and treatment of patients with penetrating neck trauma

Complications related to management/treatment measures

• The Eastern Association for the Surgery of Trauma (EAST) is a multi-disciplinary professional society committed to improving the care of injured patients. The Ad hoc Committee for Practice Management Guideline Development of EAST develops and disseminates evidence-based information to increase the scientific knowledge needed to enhance patient and clinical decision-making, improve health care quality, and promote efficiency in the organization of public and private systems of health care delivery. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors' personal observations and do not imply endorsement by nor official policy of the Eastern Association for the Surgery of Trauma.
• "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."* These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results. While guidelines can be written that take into account variations in clinical settings, resources, or common patient characteristics, they cannot address the unique needs of each patient nor the combination of resources available to a particular community or health care professional or provider. Deviations from clinical practice guidelines may be justified by individual circumstances. Thus, guidelines must be applied based on individual patient needs using professional judgment.

*Institute of Medicine. Clinical practice guidelines: directions for a new program. MJ Field and KN Lohr (eds) Washington, DC: National Academy Press. 1990: pg 39.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Tisherman SA, Bokhari F, Collier B, Ebert J, Holevar M, Cumming J, Kurek S, Leon S, Rhee P. Clinical practice guidelines: penetrating neck trauma. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2008. 52 p. [126 references]

Not applicable: The guideline was not adapted from another source.

2008

Eastern Association for the Surgery of Trauma - Professional Association

Eastern Association for the Surgery of Trauma (EAST)

EAST Practice Management Guidelines Committee

Committee Members: Samuel A. Tisherman, MD; Faran Bokhari, MD; Bryan Collier, DO; James Ebert, MD; Michele Holevar, MD; John Cumming, MD; Stanley Kurek, DO; Stuart Leon, MD; Peter Rhee, MD

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on September 12, 2008.

This NGC summary is based on the original guideline, which is copyrighted by the Eastern Association for the Surgery of Trauma (EAST).