计算机断层血管造影在有临床硬体征的Ⅱ区穿透性颈部创伤患者管理中的作用
Role of computed tomography angiography in the management of Zone II penetrating neck trauma in patients with clinical hard signs.
作者信息
Schroll Rebecca, Fontenot Tatyana, Lipcsey Megan, Heaney Jiselle Bock, Marr Alan, Meade Peter, McSwain Norman, Duchesne Juan
机构信息
From the Tulane University School of Medicine (R.S., T.F., M.L., J.B.H., P.M., N.M.); and Louisiana State University Health Sciences Center (A.M.), New Orleans; and North Oaks Health System (J.D.), Hammond, Louisiana.
出版信息
J Trauma Acute Care Surg. 2015 Dec;79(6):943-50; discussion 950. doi: 10.1097/TA.0000000000000713.
BACKGROUND
The Western Trauma Association (WTA) describes the management of Zone 2 penetrating neck trauma (PNT) and recommends neck exploration (NE) for patients with clinical hard signs (HS). We hypothesize that in stable patients with HS, the management of PNT augmented by computed tomography angiography (CTA) results in fewer negative NE results.
METHODS
This was a 4-year retrospective review of adult patients with Zone 2 PNT at a Level I trauma center. Stable patients with WTA-defined HS (airway compromise, massive subcutaneous emphysema/air bubbling through wound, expanding/pulsatile hematoma, active bleeding, shock, focal neurologic deficit, and hematemesis) who underwent CTA instead of emergent exploration were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for CTA were calculated. A comparison was made between the rates of negative NE results in patients with HS who received a CTA versus the rate that would have occurred in the same patients if the WTA algorithm had been followed. Missed injury rates were also compared.
RESULTS
Of 183 PNT patients, 23 had HS and underwent CTA. Of the 23, 5 had a positive CTA findings and underwent NE, while 17 had a negative CTA findings and did not require NE. There was one false-negative in a patient who developed an expanding hematoma following negative neck CTA finding. Sensitivity, specificity, positive predictive value, and negative predictive value for CTA in the presence of HS were found to be 83%, 100%, 100%, and 94%, respectively. The addition of CTA to the WTA algorithm for this patient group significantly decreased the rate of negative NE (0 of 23 vs. 18 of 23, p < 0.001) without a significant increase in the rate of missed injury (1 of 23 vs. 0 of 23, p = 0.323). The use of CTA prevented 17 unnecessary NEs.
CONCLUSION
CTA addition to the management of hemodynamically stable patients with HS in PNT significantly decreased the rate of negative NE result without increasing missed injury rate. Prospective study of CTA addition to the WTA algorithm is needed.
LEVEL OF EVIDENCE
Care management/therapeutic study, level IV.
背景
西方创伤协会（WTA）阐述了2区穿透性颈部创伤（PNT）的处理方法，并建议对有临床硬体征（HS）的患者进行颈部探查（NE）。我们假设，对于有HS的稳定患者，采用计算机断层血管造影（CTA）辅助处理PNT会减少阴性NE结果的发生。
方法
这是一项对某一级创伤中心成年2区PNT患者进行的为期4年的回顾性研究。确定了那些有WTA定义的HS（气道受损、大量皮下气肿/伤口有气泡冒出、不断扩大/搏动性血肿、活动性出血、休克、局灶性神经功能缺损和呕血）且接受CTA而非急诊探查的稳定患者。计算CTA的敏感性、特异性、阳性预测值和阴性预测值。对接受CTA的HS患者的阴性NE结果发生率与如果遵循WTA算法这些患者本应出现的发生率进行比较。还比较了漏诊率。
结果
在183例PNT患者中，23例有HS并接受了CTA检查。在这23例患者中，5例CTA检查结果为阳性并接受了NE，17例CTA检查结果为阴性且无需进行NE。有1例患者颈部CTA检查结果为阴性，但随后出现血肿扩大，这是1例假阴性结果。在有HS的情况下，CTA的敏感性、特异性、阳性预测值和阴性预测值分别为83%、100%、100%和94%。对于该患者群体，在WTA算法中加入CTA显著降低了阴性NE的发生率（23例中0例 vs. 23例中18例，p < 0.001），且漏诊率没有显著增加（23例中1例 vs. 23例中0例，p = 0.323）。使用CTA避免了17例不必要的NE。
结论
在血流动力学稳定的PNT且有HS的患者处理中加入CTA显著降低了阴性NE结果的发生率，且未增加漏诊率。需要对在WTA算法中加入CTA进行前瞻性研究。
证据水平
护理管理/治疗性研究，IV级。
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