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Management and outcomes of military penetrating neck injuries: An eleven-year retrospective case note review

  • Author Footnotes
    1 Present address: 4 Armoured Medical Regiment, Assaye Barracks, Tidworth, SP9 7BA, UK.
    Christopher Pickering
    Correspondence
    Corresponding author at: 4 Armoured Medical Regiment, Assaye Barracks, Tidworth SP9 7BA, UK.
    Footnotes
    1 Present address: 4 Armoured Medical Regiment, Assaye Barracks, Tidworth, SP9 7BA, UK.
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2WB, UK
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  • Jameel Muzaffar
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2WB, UK

    University of Cambridge School of Clinical Medicine, Box 111, Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK
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  • Conor Reid
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2WB, UK
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  • Benjamin Zakaria
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    University of Birmingham Medical School, College of Medical and Dental Sciences, Birmingham, B15 2TT, UK
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  • Christopher Coulson
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    University of Birmingham Medical School, College of Medical and Dental Sciences, Birmingham, B15 2TT, UK
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  • Neil Sharma
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    University of Birmingham Medical School, College of Medical and Dental Sciences, Birmingham, B15 2TT, UK
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  • John Breeze
    Affiliations
    Queen Elizabeth Hospital Birmingham, Mindelsohn Way, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK

    Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2WB, UK
    Search for articles by this author
  • Author Footnotes
    1 Present address: 4 Armoured Medical Regiment, Assaye Barracks, Tidworth, SP9 7BA, UK.
Published:November 11, 2022DOI:https://doi.org/10.1016/j.injury.2022.11.034

      Highlights

      • Penetrating neck injury management of military persons in Iraq and Afghanistan who were seen at deployed UK facilities and evacuated back to UK.
      • CTA was effective at ruling out significant vascular or aerodigestive injury.
      • UK Military surgeons had a low threshold for open neck exploration, even in patients with both a negative CTA and no clinical hard signs.

      Abstract

      Introduction

      Penetrating Neck Injuries (PNIs) affected 3.2% of trauma patients attending US and UK deployed medical treatment facilities (MTFs) during the Iraq and Afghanistan conflicts. Injured military personnel requiring aeromedical evacuation for such injuries were managed at the Royal Centre for Defence Medicine (RCDM), Birmingham, UK. The aim of this paper was to review the management of PNI in both deployed MTFs and when evacuated back to the UK.

      Patients and methods

      A retrospective case note review was performed of all military patients who sustained PNI whilst on deployment overseas, and who were subsequently evacuated to RCDM between March 2003 and December 2014.

      Results

      Forty casualties who sustained PNI were identified, of which 28/40 (70%) sustained injury from explosive fragmentation, and 11/40 (28%) from gunshot wounds. Hard signs of PNI were present in 3/40 (7.5%) patients, soft signs in 14/40 (35%), no signs in 12/40 (30%), and unknown signs in 11/40 (28%) patients. Computed tomography angiography (CTA) was used in 39/40 (98%) patients, and was effective at ruling out significant injury, with 100% (29/29) of casualties with a negative CTA not developing vascular or aerodigestive injury. There were 9/29 (31%) patients who had surgical neck exploration despite both a negative CTA and absence of hard signs of PNI. There were 12/40 (30%) patients who required operative intervention at RCDM.

      Conclusion

      UK military surgeons in Role 3 MTFs had a low threshold for surgical exploration, even in the absence of CT findings or hard signs. This was likely due to the high-energy mechanisms responsible for military PNI, in addition to the limited availability of equipment and clinical expertise in visualising the larynx.

      Keywords

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      References

        • Breeze J.
        • Bowley D.M.
        • Combes J.G.
        • Baden J.
        • Orr L.
        • Beggs A.
        • et al.
        Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: a comparison of treatment at US and United Kingdom medical treatment facilities.
        J Trauma Acute Care Surg. 2020; 88 (May 1): 696-703
        • Breeze J.
        • Allanson-Bailey L.S.
        • Hunt N.C.
        • Delaney R.S.
        • Hepper A.E.
        • Clasper J.
        Mortality and morbidity from combat neck injury.
        J Trauma Inj Infect Crit Care. 2012; 72 (Apr): 969-974
        • Owens B.D.
        • Kragh J.F.
        • Wenke J.C.
        • Macaitis J.
        • Wade C.E.
        • Holcomb J.B.
        Combat wounds in operation Iraqi freedom and operation enduring freedom.
        J Trauma Inj Infect Crit Care. 2008; 64 (Feb): 295-299
        • Breeze J.
        • Horsfall I.
        • Hepper A.
        • Clasper J.
        Face, neck, and eye protection: adapting body armour to counter the changing patterns of injuries on the battlefield.
        Br J Oral Maxillofac Surg. 2011; 49 (Dec): 602-606
        • Breeze J.
        • Masterson L.
        • Banfield G.
        Outcomes from penetrating ballistic cervical injury.
        J R Army Med Corps. 2012; 158 (Jun): 96-100
      1. Ministry of Defence. Allied Joint Doctrine for Medical Support. Allied Joint Publication-4.10(C) [Internet]. 2020 [cited 2022 Oct 24]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/922182/doctrine_nato_med_spt_ajp_4_10.pdf.

        • Roon A.J.
        • Christensen N.
        Evaluation and treatment of penetrating cervical injuries.
        J Trauma. 1979; 19 (Jun): 391-397
        • Tsur N.
        • Benov A.
        • Nadler R.
        • Tsur A.M.
        • Glick Y.
        • Radomislensky I.
        • et al.
        Neck injuries – israel defense forces 20 years’ experience.
        Injury. 2021; 52 (Feb 1): 274-280
        • Clarke J.E.
        • Davis P.R.
        Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010–April 2011.
        Mil Med. 2012; 177 (Nov 1): 1261-1266
        • Breeze J.
        • Gensheimer W.G.
        • DuBose J.J.
        Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support.
        Mil Med. 2021; 186 (Jan 30): 18-23
        • Morales-Uribe C.
        • Ramírez A.
        • Suarez-Poveda T.
        • Ortiz M.
        • Sanabria A.
        Diagnostic performance of CT angiography in neck vessel trauma: systematic review and meta-analysis.
        Emerg Radiol. 2016; 23 (Oct 1): 421-431
        • de Régloix S.B.
        • Baumont L.
        • Daniel Y.
        • Maurin O.
        • Crambert A.
        • Pons Y.
        Comparison of penetrating neck injury management in combat versus civilian trauma: a review of 55 cases.
        Mil Med. 2016; 181 (Aug): 935-940
        • Demetriades D.
        • Kimbrell B.
        • Salim A.
        • Velmahos G.
        • Rhee P.
        • Preston C.
        • et al.
        Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept?.
        J Am Coll Surg. 2005; 201 (Sep 1): 343-348
        • Shiroff A.M.
        • Gale S.C.
        • Martin N.D.
        • Marchalik D.
        • Petrov D.
        • Ahmed H.M.
        • et al.
        Penetrating neck trauma: a review of management strategies and discussion of the “No Zone” approach.
        Am Surg. 2013; 79 (Jan): 23-29
        • Inaba K.
        • Branco B.C.
        • Menaker J.
        • Scalea T.M.
        • Crane S.
        • DuBose J.J.
        • et al.
        Evaluation of multidetector computed tomography for penetrating neck injury.
        J Trauma Acute Care Surg. 2012; 72 (Mar): 576-584
        • Ibraheem K.
        • Khan M.
        • Rhee P.
        • Azim A.
        • O'Keeffe T.
        • Tang A.
        • et al.
        No zone” approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations.
        J Surg Res. 2018; 221 (Jan): 113-120
        • Vassallo D.
        A short history of Camp Bastion Hospital: part 2—Bastion's catalytic role in advancing combat casualty care.
        BMJ Mil Heal. 2015; 161 (Jun 1): 160-166
        • Fox C.J.
        • Gillespie D.L.
        • Weber M.A.
        • Cox M.W.
        • Hawksworth J.S.
        • Cryer C.M.
        • et al.
        Delayed evaluation of combat-related penetrating neck trauma.
        J Vasc Surg. 2006; 44 (Jul): 86-93
        • Cox M.W.
        • Whittaker D.R.
        • Martinez C.
        • Fox C.J.
        • Feuerstein I.M.
        • Gillespie D.L.
        Traumatic pseudoaneurysms of the head and neck: Early endovascular intervention.
        J Vasc Surg. 2007; 46 (Dec): 1227-1233
        • Zakaria B.
        • Muzaffar J.
        • Borsetto D.
        • Fussey J.
        • Kumar R.
        • Evans K.
        • et al.
        Civilian penetrating neck trauma at a level I trauma centre: a five-year retrospective case note review.
        Clin Otolaryngol. 2022; 47 (Jan 1): 44-51
        • Burgess C.A.
        • Dale O.T.
        • Almeyda R.
        • Corbridge R.J.
        An evidence based review of the assessment and management of penetrating neck trauma.
        Clin Otolaryngol. 2012; 37 (Feb): 44-52
        • Brywczynski J.J.
        • Barrett T.W.
        • Lyon J.A.
        • Cotton B.A.
        Management of penetrating neck injury in the emergency department: a structured literature review.
        Emerg Med J. 2008; 25 (Nov 1): 711-715
        • Breeze J.
        • Powers D.
        Penetrating neck injury.
        in: Breeze J. Penn-Barwell J.G. Keene D. O'Reilly D. Jeyanathan J. Mahoney P.F. Ballistic Trauma, A practical Guide. 4th ed. Springer, 2017: 257-273
        • Brennan J.
        • Lopez M.
        • Gibbons M.D.
        • Hayes D.
        • Faulkner J.
        • Dorlac W.C.
        • et al.
        Penetrating neck trauma in operation Iraqi freedom.
        Otolaryngol Neck Surg. 2011; 144 (Feb): 180-185