In the old days, stab injuries to Zone 2 in the neck meant a trip to the operating room. Then it became acceptable to evaluate stable patients with this injury via endoscopy, angiography and a swallow study. Most chief residents didn’t have the patience for this and opted for OR anyway. CT now promises to simplify the evaluation process, rolling these studies into one fast and simple one.
USC+LAC and the University of Maryland directed a prospective multicenter study that looked at the sensitivity and specificity of using CT angiography of the neck to evaluate penetrating injuries.All patients underwent a structured physical examination of the neck. If hard signs of injury to the vascular tree or aerodigestive tract were present, they were immediately taken to OR (6%). Nearly all of these patients had an injury that required repair. If they had no signs, they were merely observed (51%). None had a missed injury.
The remaining 159 patients had a positive exam (minor oozing, small stable hematoma) underwent CT angio of the neck (54% stabs, 42% gunshots, 4% other). The majority were in Zone 2 (41%), but 24% were in Zone 3, 21% in Zone 1, and 14% crossed multiple zones. Overall sensitivity was 100% and specificity was 97%. CT angio was nondiagnostic in 3 patients due to missile fragment artifact.
Bottom line: CT angio of the neck is a fast and accurate exam that can be used in stable patients with an abnormal physical exam but no hard signs of injury. This fits my bias, and we have already been using the scanner this way for stabs. I would now recommend cautiously extending its use for select gunshots as well.
Hard signs of neck injury:
- Unstable vital signs
- Large, expanding, or pulsatile hematoma
- Active bleeding
- Air bubbling
- Voice or airway disturbance
- Hematemesis / hemoptysis
- Thrill / bruit
- Neurologic deficit
Reference: Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. AAST 2011 Annual Meeting, Oral Paper 61.