The neck is a particularly critical region to sustain penetrating injuries, due to the close approximation of the trachea, esophagus, blood vessels, and the spinal cord. In our study, the mortality was associated with initial SBP at the hospital, GCS, transfusion, and AIS of the neck. Early volume resuscitation is considered essential for penetrating neck injury patients. Aggressive fluid therapy, during transfer to the hospital and in the field, would help the patient, even if the damage is severe.
The initial evaluation of a trauma patient begins with the “ABC’s” of trauma management: establish a secure airway, breathing/respiration, and volume resuscitation [3, 8, 9]. For our study, the mortality was associated with initial SBP at the hospital, GCS, and transfusion (Table 5). When SBP is low, transfusion is performed and the GCS would be low. The GCS was developed for monitoring postoperative craniotomy patients, and was subsequently applied as a means for overall physiological derangement in trauma field. Therefore, SBP is considered to be the most important factor. Additionally, the main cause of mortality was hypovolemia due to bleeding. Therefore, volume resuscitation is as important as airway management and respiration. The combined use of SBP and motor GCS is effective at predicting patient survival .
As the ISS is a severity scale derived from the anatomical based scale, the ISS is the sum of the squares of the highest AIS in each of the three most severely injured ISS body regions. So, both AIS and ISS do not reflect the physiologic state of traumatic victims. However, in this study, mortality is related to AIS of the neck.
The platysma is a thin muscular sheet, which surrounds the superficial fascia of the neck. It determines whether a penetrating wound of the neck is superficial or deep . The potential for injury to a vital organ exists when this structure is penetrated. If the platysma is penetrated in the initial survey, an active surgical intervention is required . The standard management is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound . However, all patients with active bleeding, expanding hematoma, shock, massive subcutaneous emphysema, or significant airway compromise are admitted directly to the operating room and are surgically explored, regardless of the zone of injury [3, 8]. Also, particular importance should be placed on the airway, because bleeding within the tight compartmentalized spaces of the neck may appear quiescent externally, yet cause progressive airway compromise and eventual complete obstruction . In this study, 22 patients presented with platysma penetration; significant airway or vascular injury was found in 11 patients (Table 2). Mandatory surgical exploration was once warranted, if platysma penetration was present. Today, mandatory surgical exploration for all injuries that penetrate the platysma is no longer practiced . Nonetheless, mandatory exploration of all neck wounds may be the best policy in an environment in which routine serial examinations are not possible .
CTA is generally considered the initial diagnostic method to evaluate the injured organs in penetrating neck trauma . Comprehensive physical examination with CTA is adequate for identifying and excluding vascular and aerodigestive injury due to penetrating neck trauma . In this study, all patients with stable vital signs were taken for a CTA. We determined the surgical strategy from this CTA. As the accuracy of the CTA increases, with careful clinical evaluation to diagnose critical structures damage, surgical intervention or observation is performed safely and carefully . In a trauma center with experienced staff, the frequency of operations for penetrating neck wounds without structural injuries can be minimized by selective neck exploration [13, 14].
In this study, 6183 patients visited our hospital over a three year period. Thirty-two patients presented with penetrating neck injury. Five patients died. Although penetrating neck injury was estimated as 10% of all trauma patients, the overall mortality rates were estimated at between 3–6%, most commonly as a result of injury to vascular structures, causing hemorrhage [2, 3, 4]. The results of this study seem to be similar to those of previous studies. There are many important structures in the neck. Therefore, it seems that the AIS of the neck is more related to damage than the ISS. And early “ABC’s” is very important. The neck is a particularly critical region to sustain penetrating injuries, due to the close approximation of the trachea, esophagus, blood vessels, and the spinal cord.