Penetrierende Verletzungen des Halses: Charakterisierung eines südafrikanischen Patientenkollektivs, Einflussfaktoren auf Diagnostik, Therapie, Komplikationsrate und Mortalität

Background: Since the beginning of the 20th century factors influencing the treatment of penetrating neck injuries are under debate. Besides the management itself the differences between gunshot wounds and stab wounds, the anatomical classification of the neck and the diagnosis of visceral injuries by the physical examination, the computed tomographic angiography (CTA) and the oesophagography were in the center of many publications. The aim of this study is to clarify and improve diagnostic and treatment strategies of penetrating neck injuries. Therefore, a characterization of a South African patient collective regarding epidemiology, mechanism and anatomical location of injury, vital signs, diagnostic and therapeutic modalities, complications and mortality rate was conducted. Secondly, this work evaluates the effect of the mechanism of injury and of the affected zone onto the treatment. Finally, the accuracy of the physical examination, the CTA and the oesophagography were examined. Methods: 303 patients with penetrating neck injury who were admitted to the Chris Hani Baragwanath Hospital in Johannesburg, South Africa from March 2010 to April 2011 were included in this study and retrospectively analyzed. The treatment followed the principles known as selective non-operative management (SNOM). In accordance with the hospital´s algorithm the decision for surgical intervention was based on clinical examination and the results of diagnostic investigations. Not all patients with vascular ‘hard signs’ (missing peripheral pulses, side difference of the pulses, thrill, bruit, expanding or pulsatile hematoma) and aerodigestive ‘hard signs’ (emphysema, dysphagia, hematemesis, bubbling wound, hemoptysis, hoarseness) underwent exploration. Results: Out of the 303 patients included in the study 265 presented with stab wounds, 30 had gunshot wounds and 8 had injuries from another mechanism. 90.8% were treated due to a single wound whereas 9.2% sustained multiple injuries. ‘Hard signs’ for vascular trauma were present in 31 patients and ‘hard signs’ for aerodigestive trauma in 49 patients. 163 patients underwent CTA. Oesophagography was performed in 56 patients. 169 patients (55.8%) were managed conservatively and 134 (44.2%) surgically. Complications occurred in 9.9%. In-hospital mortality rate was 2.3%. Patients with stab wounds received a CTA significantly more rarely (p=0.012). Concerning stab wounds, treatment in the emergency room was different in this type of injury: the wound was sutured more often directly in the emergency room (p=0.005) and an intubation (p=0.005) and an immobilization of the cervical spine (p=0.000) was performed not as often as after gunshot wounds. Additionally, the complication rate was decreased in patients with stab wounds (p=0.009). Concerning the classification of the neck wounds the posterior triangle were significantly more often managed conservatively (p=0.039). Vascular injuries were more common in zone II of the neck (p=0.013). The sensitivity and specificity of vascular ‘hard signs’ were 24.1% and 92.8% respectively. Aerodigestive ‘hard signs’ had a sensitivity and a specificity of 42.3% and 86.3% respectively. CTA achieved a 63.6% sensitivity and 91.2% specificity. Oesophagography showed a sensitivity and specificity of 42.9% and 95.3% respectively. Conclusion: The management of penetrating neck injuries should be based on physical examination and additional investigations for all patients. ‘Hard signs’ are no indication for a mandatory surgical exploration, but a conservative treatment is possible, if the results of the additional investigations are justifying this approach. Because of the higher destructive power and as a result the higher complication rate of gunshot wounds the emergency management differs from the treatment of stab wounds. The anatomical localization of the injury has little importance for the diagnostic approach and the definitive therapy. High specificities of the physical examination and the radiological investigations suggest a visceral trauma in case of a pathological result. Due to low sensitivities of the clinical signs, the CTA and oesophagography a clear recommendation for the improvement of diagnostic and therapeutic strategies cannot be proposed in this study.