Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California 90033-4525, USA.
J Trauma Acute Care Surg. 2012 Mar;72(3):576-83; discussion 583-4; quiz 803-4. doi: 10.1097/TA.0b013e31824badf7.
The purpose of this prospective multicenter study was to evaluate a clinical protocol integrating multidetector computed tomographic angiography (MDCTA) as the initial screening examination for the work-up of penetrating neck injury.
All penetrating neck injuries assessed at two Level I trauma centers (January 2009-July 2011) prospectively underwent a structured clinical examination. Those with hard signs of injury (active bleed, instability, expanding/pulsatile hematoma, bruit/thrill, hemoptysis, hematemesis, and air bubbling) underwent exploration, those who were asymptomatic were observed. The remainder, with soft signs underwent MDCTA. Sensitivity and specificity were tested against an aggregate gold standard of operative intervention, clinical follow-up, and when obtained, conventional angiography, bronchoscopy, esophagogram, and esophagoscopy.
Four hundred fifty-three penetrating neck injuries were evaluated. Hard signs of vascular or aerodigestive tract injury were observed in 8.6% with an 89.7% incidence of clinically significant injury. 41.7% had no signs of injury and were observed with no missed injuries (follow-up, 2.6 days ± 1.1 days [1-58 days]). The remaining 225 (49.7%) underwent MDCTA (stab wound, 61.3%; gunshot wound, 37.8%; shotgun, 0.9%). The external wounds were in zone II (38.2%), multiple (28.9%), zone I (16.9%), and zone III (16.0%). Twenty-eight injuries were found in 22 patients (5 internal jugular-V, 2 external jugular-V, 1 vertebral-A, 7 common carotid-A, 2 internal carotid-A, 3 external carotid-A, 2 subclavian-A, 3 esophagus, and 3 tracheas). Five patients had false-positive findings (2 vascular and 3 aerodigestive tract). The 194 negative studies (follow-up, 5.5 days ± 7.5 days [1-27 days]) had no delayed diagnosis of injury. MDCTA was nondiagnostic in four patients (1.8%), secondary to artifact. One of these had a vertebral-A injury diagnosed at angiography. MDCTA achieved 100% sensitivity and 97.5% specificity in detecting all clinically significant injuries.
In the initial evaluation of patients who have sustained penetrating neck trauma, physical examination can safely reduce unnecessary imaging. If imaging is required, MDCTA is a highly sensitive and specific screening modality for evaluating the vascular and aerodigestive structures in the neck.
II, prospective study.
本前瞻性多中心研究的目的是评估一种将多排螺旋 CT 血管造影（MDCTA）作为穿透性颈部损伤检查初始筛查的临床方案。
在两个一级创伤中心（2009 年 1 月至 2011 年 7 月）评估的所有穿透性颈部损伤均进行了结构化的临床检查。有明确损伤体征（活动性出血、不稳定、进行性或搏动性血肿、杂音/震颤、咯血、呕血和气泡）的患者接受了探查，无症状的患者则进行观察。其余有软组织损伤体征的患者进行 MDCTA 检查。对手术干预、临床随访以及获得的常规血管造影、支气管镜、食管造影和食管镜检查的综合金标准进行了敏感性和特异性测试。
共评估了 453 例穿透性颈部损伤。有 8.6%的患者出现血管或呼吸道损伤的明确体征，其中 89.7%的患者存在临床显著损伤。41.7%的患者无损伤体征，接受观察，无漏诊（随访时间为 2.6 天±1.1 天[1-58 天]）。其余 225 例（49.7%）进行了 MDCTA 检查（刺伤 61.3%；枪伤 37.8%；霰弹枪伤 0.9%）。外部伤口位于Ⅱ区（38.2%）、多处（28.9%）、Ⅰ区（16.9%）和Ⅲ区（16.0%）。22 例患者中发现 28 处损伤（5 例颈内静脉-V、2 例颈外静脉-V、1 例椎动脉-A、7 例颈总动脉-A、2 例颈内动脉-A、3 例颈外动脉-A、2 例锁骨下动脉-A、3 例食管和 3 例气管）。5 例患者出现假阳性结果（2 例血管损伤和 3 例呼吸道损伤）。194 例阴性研究（随访时间为 5.5 天±7.5 天[1-27 天]）无延迟诊断损伤。4 例（1.8%）MDCTA 检查无诊断价值，主要是由于伪影。其中 1 例经血管造影检查发现椎动脉-A 损伤。MDCTA 对所有临床显著损伤的敏感性和特异性均为 100%。
在穿透性颈部创伤患者的初始评估中，体格检查可安全减少不必要的影像学检查。如果需要影像学检查，MDCTA 是一种高度敏感和特异的筛查方法，可用于评估颈部的血管和呼吸道结构。
Ⅱ级，前瞻性研究。
