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Penetrating neck trauma in children: An urban hospital's experience
Penetrating neck trauma in children: An urban hospital’s experience MICHAEL K. KIM, MD, ROBERT BUCKMAN, MD, FACS, and WASYL SZEREMETA, MD, FAAP, Philadelphia, Pennsylvania
OBJECTIVE: As the incidence of violent crime increases in our society, the rate of penetrating head and neck trauma in children also rises. The methods of management of pediatric penetrating neck wounds are addressed. METHODS: All clinical records of children younger than 18 years admitted with penetrating neck injuries between 1990 and 1997 were reviewed. The injuries were classified according to type and location of the neck wound. Demographic data, clinical presentation, diagnostic studies, and management techniques were evaluated. RESULTS: Thirty-five children aged 6 to 18 years old were evaluated for 31 missile wounds and 4 stab wounds. There were 30 boys and 5 girls. Fourteen percent of injuries were in zone 1, 60% in zone II, and 26% in zone III. Of the 33% of children with zone II penetrating neck traumas who underwent selective neck explorations, 86% had significant intraoperative findings. The mortality rates for zones I, II, and III were 60%, 29%, and 56%, respectively. The overall mortality rate was 40%. CONCLUSIONS: Penetrating neck trauma in children may lead to potentially life-threatening injuries. Selective management of penetrating head and neck injuries in children can be a safe and effective policy in an experienced trauma center. (Otolaryngol Head Neck Surg 2000;123:439-43.)
During the past decade, penetrating neck injuries in children have increasingly become a major urban medFrom the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine (Dr Kim); and Temple University School of Medicine (Drs Buckman and Szeremeta). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 26-29, 1999. Reprint requests: Michael K. Kim, MD, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 5 Silverstein/Ravdin, Philadelphia, PA 19104. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/1/109760 doi:10.1067/mhn.2000.109760
ical problem. Although penetrating neck injuries due to firearm missiles and stab wounds are uncommon among the pediatric population, they have been shown to cause significant morbidity and mortality for this age group.1,2 The continued debate over the ideal protocol for the management of penetrating neck injuries in children parallels the controversy involving the mandatory versus selective management of penetrating neck trauma in adults. However, only limited information exists in the literature regarding the management of penetrating neck trauma in children.3 The purpose of this study was to evaluate the extent and consequences of penetrating neck trauma in children. Additionally, the management of pediatric penetrating neck trauma in an urban hospital setting is also reviewed. METHODS We reviewed the records of all children aged 18 years and younger who were admitted with a diagnosis of penetrating neck injury between 1990 and 1997. The demographic data, clinical presentation, diagnostic studies, and management techniques were reviewed. All of the children were initially evaluated within the trauma bay in the emergency department. The emergency department physicians and the surgical trauma team treated all of the children by following the standard advanced-trauma life-support protocol. The neck injuries were classified according to the type and location of the wound by dividing the neck into 3 zones: zone I, below the cricoid cartilage; zone II, between the cricoid cartilage and the angle of the mandible; and zone III, above the angle of the mandible. RESULTS
Thirty-five children sustained penetrating neck injuries between 1990 and 1997. There were 30 boys and 5 girls aged 6 to 18 years (mean 15 years). Missiles injured 31 (89%), and stab wounds injured only 4 (11%) of these children. Most (60%) of the penetrating neck wounds involved zone II (n = 21); 26% (n = 9) of the neck injuries were in zone III, and 14% (n = 5) were in zone I. Sixty percent of patients with zone I neck wounds also had multiple other associated chest and abdominal injuries, 439
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Fig 1. Trauma score (TS) criteria.4
whereas 56% of patients with zone III neck wounds had associated brain injuries. Sixty percent (n = 21) of the children underwent surgical neck explorations. Eighty percent of zone I, 52% of zone II, and 67% of zone III penetrating neck injuries resulted in surgical neck explorations. All of the surgical neck explorations for zones I and III were mandatory. The mandatory neck explorations for zones I and III were associated with hemodynamically unstable patients who presented with massive uncontrollable bleeding from either the neck or associated anatomic regions, including the thorax and cranium. Seventeen of the 21 patients with zone II penetrating neck injuries underwent several different management protocols, including mandatory neck exploration (n = 4), selective neck exploration (n = 7), or observation (n
= 6), and 4 died before their arrival at the emergency department. The 4 children who underwent mandatory neck explorations had massive bleeding or airway distress from their zone II neck injuries. All 4 mandatory neck explorations yielded a positive finding of a significant vascular or aerodigestive tract injury within the neck. The 7 patients treated with selective neck exploration had significant findings on routine clinical examinations or diagnostic studies, and 86% (n = 6) of these children had positive findings (Table 1). A single patient in whom dysphagia developed did not have any significant findings during panendoscopy and therefore did not undergo a surgical neck exploration. All 6 patients who underwent observation after initially being evaluated by the emergency department staff and surgical trauma team were discharged without requiring further
Otolaryngology– Head and Neck Surgery Volume 123 Number 4
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Table 1. Criteria for selective neck exploration in 6 patients Patient number
Physical exam
1 2 3 4 5 6
Stridor Stridor Dysphagia Dysphagia Changing neck exam Foreign body adjacent to vital structures
Diagnostic studies
Panendoscopy Panendoscopy Panendoscopy Panendoscopy CT scan of neck Neck x-ray
Injuries
Trachea Larynx Esophagus Esophagus Hematoma Small-vessel injury
medical treatment. None of these 6 had delayed complications of any kind. The 35 patients reviewed in this study had a total of 48 separate neck injuries involving either vascular, neurologic, or aerodigestive tract structures within the neck. Overall, there were injuries to 20 vascular structures, 15 neurologic structures, 3 digestive tract structures, and 10 upper respiratory tract structures (Table 2). Multiple missile wounds were found in 100% of zone I, 52% of zone II, and 100% of zone III penetrating neck injuries. All 14 children who died of missile wounds had trauma scores of 3 at the time of evaluation in the trauma bay (Fig 1).4 The seriousness of these missile injuries resulted in a mortality rate of 40% (n = 14). The mortality rate of patients with zone I injuries was 60% (n = 3), zone II injuries 29% (n = 6), and zone III injuries 56% (n = 5). Three patients with trauma scores of 3 at the time of their initial evaluation survived their missile injuries. DISCUSSION
Injuries by firearms have reached epidemic proportions, causing the loss of thousands of lives and a financial burden to the health care system.5 Firearm injuries are the second leading cause of death for young people aged 10 to 24 years. As of 1994, 29% of those who died of firearm injuries were 15 to 24 years old. In 1995, 7% (1 in 12) of students in a national survey reported carrying a firearm for fighting or self-defense at least once in the previous 30 days. Additionally, between 1985 and 1994, the risk of dying from a firearm injury has more than doubled for teenagers 15 to 19 years of age.6 Penetrating neck injuries present complex management problems for the surgical trauma team because of the major vascular, neurologic, aerodigestive tract, and soft tissue structures that are at risk for injury. There is little disagreement that patients with zone II neck injuries exhibiting signs or symptoms suggestive of significant vascular or visceral injuries must undergo mandatory neck exploration.2,7,8 However, there is con-
441
Table 2. Injuries to various structures Structure
Vascular Common carotid artery External carotid artery branches Vertebral artery Internal jugular vein Subclavian vein Minor vessel injuries Neurologic Central nervous system Spinal cord Cranial nerve Sympathetic chain Brachial plexus Aerodigestive tract Larynx Trachea Esophagus
n
4 2 3 6 3 2 6 5 1 2 1 4 6 3
siderable controversy regarding the treatment of children who have penetrating neck wounds without initial clinical manifestations of injuries to vital structures within the neck.2,7,8 The controversial debate over mandatory versus selective neck exploration for zone II neck injuries has historical origins beginning before World War II. Before World War II, penetrating neck injuries were managed expectantly with a mortality rate of 15% to 18%. The mortality rate of penetrating neck injuries was reduced to 3% to 7% during World War II, with early exploration of all zone II neck wounds penetrating the platysma.9 Fogelman and Stewart10 also confirmed that low mortality rates are associated with mandatory neck explorations for neck wounds penetrating the platysma in the civilian population. Although mandatory neck exploration for all neck wounds penetrating the platysma reduced the mortality rates, this approach also resulted in negative exploration rates of 33% to 76%.3,7,10 Therefore the role of mandatory neck exploration, with its associated morbidity, has been challenged with arguments for selective neck explorations.9,11 The indications for mandatory neck explorations in this study include the following: (1) continued bleeding from the wound, hematoma, or shock; (2) blood in the aerodigestive tract; (3) subcutaneous emphysema, hoarseness, or aphonia; (4) neurologic deficits; and (5) inability to observe or study the child because of other injuries. Other authors have recommended similar protocols for mandatory neck explorations.3,7,11 Selective management of penetrating neck injuries involves operating only in the presence of clinical findings suggestive of a significant injury.3,7,9 Every patient
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Fig 2. Management of pediatric penetrating neck trauma.
with a penetrating neck injury who did not meet the criteria for mandatory neck exploration underwent a series of diagnostic studies including radiologic imaging studies and endoscopic evaluation of the upper aerodigestive tract in addition to an intensive clinical observation period of 24 hours. Patients with changes in their clinical examinations or abnormal findings on diagnostic studies were taken to the operating room for selective neck explorations. In our study, 86% (n = 6) of the patients who underwent selective neck explorations were found to have significant injuries to either vascular, neurologic, or upper aerodigestive tract structures. Additionally, no major injuries developed in any patients who had been observed. Interestingly, only a few studies in the literature address missile injuries to the zone II region of the neck in children.3,7,8 Mutabagani et al7 studied 10 children who underwent selective neck explorations for zone II penetrating neck injuries. They found the rate of nega-
tive explorations to be 0% if the patients had positive results from their diagnostic studies or significant neurologic symptoms. However, the rate of negative neck explorations was 100% if the patients had been explored for injury in zone II or proximity of missile to major vascular structures, or if there were no clear indications for neck explorations. Hall et al3 reviewed 4 children who underwent selective neck explorations. There were no significant diagnostic findings in these 4 children, and they were all discharged from the hospital after a critical observation period without undergoing a neck exploration. Although Cooper et al8 did not delineate the penetrating neck injuries into specific zones of the neck, they did follow a selective neck exploration protocol. Only patients with significant findings on their diagnostic studies underwent selective neck explorations. Additionally, several studies within the adult trauma literature report positive findings in selective neck explorations ranging from 40% to 70%.9-11
Otolaryngology– Head and Neck Surgery Volume 123 Number 4
Our approach to the management of penetrating neck injuries in children emphasizes the selective approach to neck exploration. By emphasizing preoperative diagnostic evaluation and clinical observation, we have been able to reduce the rates of negative neck explorations in children with zone II penetrating neck injuries. The preoperative diagnostic evaluation has also led to a more directed approach when performing selective neck explorations (Fig 2). Our level 1 trauma center is equipped to perform diagnostic studies immediately and has specially trained health care workers who can observe patients clinically in an intensive care environment. Additionally, we have 24-hour availability of all major specialties of medicine including the different subspecialties within otolaryngology. The presence of a highly skilled surgical trauma team and ancillary support staff has led to a disciplined approach to managing penetrating neck injuries in children. CONCLUSION
Penetrating neck trauma in children may lead to potentially life-threatening injuries. A prompt diagnosis, a systematic treatment protocol, and an experienced trauma team are necessary to prevent potentially catastroph-
KIM et al
443
ic complications. The selective management of penetrating neck injuries in children can be a safe and effective management policy in an experienced trauma center. REFERENCES 1. Ordog GJ, Prakash A, Wasserberger J, et al. Pediatric gunshot wounds. J Trauma 1987;27:1272-8. 2. Martin WS, Gussack GS. Pediatric penetrating head and neck trauma. Laryngoscope 1990;100:1288-91. 3. Hall JR, Reyes HM, Meller JL. Penetrating zone-II neck injuries in children. J Trauma 1991;31:1614-7. 4. Champion HR, Sallo WJ, Camazzo AJ, et al. Trauma score. Crit Care Med 1981;9:672-6. 5. Kountakis SE, Rafie JJ, Ghorayer B, et al. Pediatric gunshot wounds to the head and neck. Otolaryngol Head Neck Surg 1996;114:756-60. 6. Hall JR, Reyes HM, Meller JL, et al. The new epidemic in children: penetrating injuries. J Trauma 1995;39:487-91. 7. Mutabagani KH, Beaver BL, Cooney DR, et al. Penetrating neck trauma in children: a reappraisal. J Pediatr Surg 1995;30:341-4. 8. Cooper A, Barlow B, Niemirska M, et al. Fifteen years’ experience with penetrating trauma to the head and neck in children. J Pediatr Surg 1987;22:24-7. 9. Meyer JP, Barret JA, Schuler JJ, et al. Mandatory vs. selective exploration for penetrating neck trauma: a prospective assessment. Arch Surg 1987;592-7. 10. Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956;91:581-96. 11. Prakashchandra MR, Bhatti MF, Gaudino J, et al. Penetrating injuries of the neck: criteria for exploration. J Trauma 1983;23: 47-9.
OBJECTIVE: As the incidence of violent crime increases in our society, the rate of penetrating head and neck trauma in children also rises. The methods of management of pediatric penetrating neck wounds are addressed. METHODS: All clinical records of children younger than 18 years admitted with penetrating neck injuries between 1990 and 1997 were reviewed. The injuries were classified according to type and location of the neck wound. Demographic data, clinical presentation, diagnostic studies, and management techniques were evaluated. RESULTS: Thirty-five children aged 6 to 18 years old were evaluated for 31 missile wounds and 4 stab wounds. There were 30 boys and 5 girls. Fourteen percent of injuries were in zone 1, 60% in zone II, and 26% in zone III. Of the 33% of children with zone II penetrating neck traumas who underwent selective neck explorations, 86% had significant intraoperative findings. The mortality rates for zones I, II, and III were 60%, 29%, and 56%, respectively. The overall mortality rate was 40%. CONCLUSIONS: Penetrating neck trauma in children may lead to potentially life-threatening injuries. Selective management of penetrating head and neck injuries in children can be a safe and effective policy in an experienced trauma center. (Otolaryngol Head Neck Surg 2000;123:439-43.)
During the past decade, penetrating neck injuries in children have increasingly become a major urban medFrom the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine (Dr Kim); and Temple University School of Medicine (Drs Buckman and Szeremeta). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 26-29, 1999. Reprint requests: Michael K. Kim, MD, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 5 Silverstein/Ravdin, Philadelphia, PA 19104. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/1/109760 doi:10.1067/mhn.2000.109760
ical problem. Although penetrating neck injuries due to firearm missiles and stab wounds are uncommon among the pediatric population, they have been shown to cause significant morbidity and mortality for this age group.1,2 The continued debate over the ideal protocol for the management of penetrating neck injuries in children parallels the controversy involving the mandatory versus selective management of penetrating neck trauma in adults. However, only limited information exists in the literature regarding the management of penetrating neck trauma in children.3 The purpose of this study was to evaluate the extent and consequences of penetrating neck trauma in children. Additionally, the management of pediatric penetrating neck trauma in an urban hospital setting is also reviewed. METHODS We reviewed the records of all children aged 18 years and younger who were admitted with a diagnosis of penetrating neck injury between 1990 and 1997. The demographic data, clinical presentation, diagnostic studies, and management techniques were reviewed. All of the children were initially evaluated within the trauma bay in the emergency department. The emergency department physicians and the surgical trauma team treated all of the children by following the standard advanced-trauma life-support protocol. The neck injuries were classified according to the type and location of the wound by dividing the neck into 3 zones: zone I, below the cricoid cartilage; zone II, between the cricoid cartilage and the angle of the mandible; and zone III, above the angle of the mandible. RESULTS
Thirty-five children sustained penetrating neck injuries between 1990 and 1997. There were 30 boys and 5 girls aged 6 to 18 years (mean 15 years). Missiles injured 31 (89%), and stab wounds injured only 4 (11%) of these children. Most (60%) of the penetrating neck wounds involved zone II (n = 21); 26% (n = 9) of the neck injuries were in zone III, and 14% (n = 5) were in zone I. Sixty percent of patients with zone I neck wounds also had multiple other associated chest and abdominal injuries, 439
440
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Fig 1. Trauma score (TS) criteria.4
whereas 56% of patients with zone III neck wounds had associated brain injuries. Sixty percent (n = 21) of the children underwent surgical neck explorations. Eighty percent of zone I, 52% of zone II, and 67% of zone III penetrating neck injuries resulted in surgical neck explorations. All of the surgical neck explorations for zones I and III were mandatory. The mandatory neck explorations for zones I and III were associated with hemodynamically unstable patients who presented with massive uncontrollable bleeding from either the neck or associated anatomic regions, including the thorax and cranium. Seventeen of the 21 patients with zone II penetrating neck injuries underwent several different management protocols, including mandatory neck exploration (n = 4), selective neck exploration (n = 7), or observation (n
= 6), and 4 died before their arrival at the emergency department. The 4 children who underwent mandatory neck explorations had massive bleeding or airway distress from their zone II neck injuries. All 4 mandatory neck explorations yielded a positive finding of a significant vascular or aerodigestive tract injury within the neck. The 7 patients treated with selective neck exploration had significant findings on routine clinical examinations or diagnostic studies, and 86% (n = 6) of these children had positive findings (Table 1). A single patient in whom dysphagia developed did not have any significant findings during panendoscopy and therefore did not undergo a surgical neck exploration. All 6 patients who underwent observation after initially being evaluated by the emergency department staff and surgical trauma team were discharged without requiring further
Otolaryngology– Head and Neck Surgery Volume 123 Number 4
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Table 1. Criteria for selective neck exploration in 6 patients Patient number
Physical exam
1 2 3 4 5 6
Stridor Stridor Dysphagia Dysphagia Changing neck exam Foreign body adjacent to vital structures
Diagnostic studies
Panendoscopy Panendoscopy Panendoscopy Panendoscopy CT scan of neck Neck x-ray
Injuries
Trachea Larynx Esophagus Esophagus Hematoma Small-vessel injury
medical treatment. None of these 6 had delayed complications of any kind. The 35 patients reviewed in this study had a total of 48 separate neck injuries involving either vascular, neurologic, or aerodigestive tract structures within the neck. Overall, there were injuries to 20 vascular structures, 15 neurologic structures, 3 digestive tract structures, and 10 upper respiratory tract structures (Table 2). Multiple missile wounds were found in 100% of zone I, 52% of zone II, and 100% of zone III penetrating neck injuries. All 14 children who died of missile wounds had trauma scores of 3 at the time of evaluation in the trauma bay (Fig 1).4 The seriousness of these missile injuries resulted in a mortality rate of 40% (n = 14). The mortality rate of patients with zone I injuries was 60% (n = 3), zone II injuries 29% (n = 6), and zone III injuries 56% (n = 5). Three patients with trauma scores of 3 at the time of their initial evaluation survived their missile injuries. DISCUSSION
Injuries by firearms have reached epidemic proportions, causing the loss of thousands of lives and a financial burden to the health care system.5 Firearm injuries are the second leading cause of death for young people aged 10 to 24 years. As of 1994, 29% of those who died of firearm injuries were 15 to 24 years old. In 1995, 7% (1 in 12) of students in a national survey reported carrying a firearm for fighting or self-defense at least once in the previous 30 days. Additionally, between 1985 and 1994, the risk of dying from a firearm injury has more than doubled for teenagers 15 to 19 years of age.6 Penetrating neck injuries present complex management problems for the surgical trauma team because of the major vascular, neurologic, aerodigestive tract, and soft tissue structures that are at risk for injury. There is little disagreement that patients with zone II neck injuries exhibiting signs or symptoms suggestive of significant vascular or visceral injuries must undergo mandatory neck exploration.2,7,8 However, there is con-
441
Table 2. Injuries to various structures Structure
Vascular Common carotid artery External carotid artery branches Vertebral artery Internal jugular vein Subclavian vein Minor vessel injuries Neurologic Central nervous system Spinal cord Cranial nerve Sympathetic chain Brachial plexus Aerodigestive tract Larynx Trachea Esophagus
n
4 2 3 6 3 2 6 5 1 2 1 4 6 3
siderable controversy regarding the treatment of children who have penetrating neck wounds without initial clinical manifestations of injuries to vital structures within the neck.2,7,8 The controversial debate over mandatory versus selective neck exploration for zone II neck injuries has historical origins beginning before World War II. Before World War II, penetrating neck injuries were managed expectantly with a mortality rate of 15% to 18%. The mortality rate of penetrating neck injuries was reduced to 3% to 7% during World War II, with early exploration of all zone II neck wounds penetrating the platysma.9 Fogelman and Stewart10 also confirmed that low mortality rates are associated with mandatory neck explorations for neck wounds penetrating the platysma in the civilian population. Although mandatory neck exploration for all neck wounds penetrating the platysma reduced the mortality rates, this approach also resulted in negative exploration rates of 33% to 76%.3,7,10 Therefore the role of mandatory neck exploration, with its associated morbidity, has been challenged with arguments for selective neck explorations.9,11 The indications for mandatory neck explorations in this study include the following: (1) continued bleeding from the wound, hematoma, or shock; (2) blood in the aerodigestive tract; (3) subcutaneous emphysema, hoarseness, or aphonia; (4) neurologic deficits; and (5) inability to observe or study the child because of other injuries. Other authors have recommended similar protocols for mandatory neck explorations.3,7,11 Selective management of penetrating neck injuries involves operating only in the presence of clinical findings suggestive of a significant injury.3,7,9 Every patient
442
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Fig 2. Management of pediatric penetrating neck trauma.
with a penetrating neck injury who did not meet the criteria for mandatory neck exploration underwent a series of diagnostic studies including radiologic imaging studies and endoscopic evaluation of the upper aerodigestive tract in addition to an intensive clinical observation period of 24 hours. Patients with changes in their clinical examinations or abnormal findings on diagnostic studies were taken to the operating room for selective neck explorations. In our study, 86% (n = 6) of the patients who underwent selective neck explorations were found to have significant injuries to either vascular, neurologic, or upper aerodigestive tract structures. Additionally, no major injuries developed in any patients who had been observed. Interestingly, only a few studies in the literature address missile injuries to the zone II region of the neck in children.3,7,8 Mutabagani et al7 studied 10 children who underwent selective neck explorations for zone II penetrating neck injuries. They found the rate of nega-
tive explorations to be 0% if the patients had positive results from their diagnostic studies or significant neurologic symptoms. However, the rate of negative neck explorations was 100% if the patients had been explored for injury in zone II or proximity of missile to major vascular structures, or if there were no clear indications for neck explorations. Hall et al3 reviewed 4 children who underwent selective neck explorations. There were no significant diagnostic findings in these 4 children, and they were all discharged from the hospital after a critical observation period without undergoing a neck exploration. Although Cooper et al8 did not delineate the penetrating neck injuries into specific zones of the neck, they did follow a selective neck exploration protocol. Only patients with significant findings on their diagnostic studies underwent selective neck explorations. Additionally, several studies within the adult trauma literature report positive findings in selective neck explorations ranging from 40% to 70%.9-11
Otolaryngology– Head and Neck Surgery Volume 123 Number 4
Our approach to the management of penetrating neck injuries in children emphasizes the selective approach to neck exploration. By emphasizing preoperative diagnostic evaluation and clinical observation, we have been able to reduce the rates of negative neck explorations in children with zone II penetrating neck injuries. The preoperative diagnostic evaluation has also led to a more directed approach when performing selective neck explorations (Fig 2). Our level 1 trauma center is equipped to perform diagnostic studies immediately and has specially trained health care workers who can observe patients clinically in an intensive care environment. Additionally, we have 24-hour availability of all major specialties of medicine including the different subspecialties within otolaryngology. The presence of a highly skilled surgical trauma team and ancillary support staff has led to a disciplined approach to managing penetrating neck injuries in children. CONCLUSION
Penetrating neck trauma in children may lead to potentially life-threatening injuries. A prompt diagnosis, a systematic treatment protocol, and an experienced trauma team are necessary to prevent potentially catastroph-
KIM et al
443
ic complications. The selective management of penetrating neck injuries in children can be a safe and effective management policy in an experienced trauma center. REFERENCES 1. Ordog GJ, Prakash A, Wasserberger J, et al. Pediatric gunshot wounds. J Trauma 1987;27:1272-8. 2. Martin WS, Gussack GS. Pediatric penetrating head and neck trauma. Laryngoscope 1990;100:1288-91. 3. Hall JR, Reyes HM, Meller JL. Penetrating zone-II neck injuries in children. J Trauma 1991;31:1614-7. 4. Champion HR, Sallo WJ, Camazzo AJ, et al. Trauma score. Crit Care Med 1981;9:672-6. 5. Kountakis SE, Rafie JJ, Ghorayer B, et al. Pediatric gunshot wounds to the head and neck. Otolaryngol Head Neck Surg 1996;114:756-60. 6. Hall JR, Reyes HM, Meller JL, et al. The new epidemic in children: penetrating injuries. J Trauma 1995;39:487-91. 7. Mutabagani KH, Beaver BL, Cooney DR, et al. Penetrating neck trauma in children: a reappraisal. J Pediatr Surg 1995;30:341-4. 8. Cooper A, Barlow B, Niemirska M, et al. Fifteen years’ experience with penetrating trauma to the head and neck in children. J Pediatr Surg 1987;22:24-7. 9. Meyer JP, Barret JA, Schuler JJ, et al. Mandatory vs. selective exploration for penetrating neck trauma: a prospective assessment. Arch Surg 1987;592-7. 10. Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956;91:581-96. 11. Prakashchandra MR, Bhatti MF, Gaudino J, et al. Penetrating injuries of the neck: criteria for exploration. J Trauma 1983;23: 47-9.