The objective of this study was to assess the role of clinical examination, angiography, color flow Doppler imaging, and other diagnostic tests in identifying injuries to the vascular or aerodigestive structures in patients with penetrating injuries to the neck. A prospective study was made of patients with penetrating neck injuries. All patients had a careful physical examination according to a written protocol. Stable patients underwent routine four-vessel angiography and color flow Doppler imaging. Esophagography and endoscopy were performed for proximity injuries. The sensitivity, specificity, and predictive values of physical examination, color flow Doppler studies, and other diagnostic tests were assessed during the evaluation of vascular and aerodigestive tract structures in the neck. Altogether 223 patients were entered in the study. After physical examination 176 patients underwent angiography and 99 of them underwent color flow Doppler imaging. Angiographic abnormalities were seen in 34 patients for an incidence of 19.3%, but only 14 (8.0%) required treatment. Color flow Doppler imaging was performed on 99 patients with a sensitivity of 91.7%, specificity 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 99%. These values were all 100% when only injuries requiring treatment were considered. None of the 160 patients without clinical signs of vascular injury had serious vascular trauma requiring treatment (NPV 100%), although angiography in 127 showed 11 vascular lesions not requiring treatment. "Hard" signs on clinical examination (large expanding hematomas, severe active bleeding, shock not responding to fluids, diminished radial pulse, bruit) reliably predicted major vascular trauma requiring treatment. Among 34 of the 223 total patients (15.2%) admitted with "soft" signs, 8 had angiographically detected injuries, but only one required treatment. An esophagogram was performed on 98 patients because of proximity injuries (49 patients) or suspicious clinical signs (49 patients), and two of them showed esophageal perforations. None of the 167 patients without clinical signs of esophageal trauma had an esophageal injury requiring treatment. It was concluded that physical examination is reliable for identifying those patients with penetrating injuries of the neck who require vascular or esophageal diagnostic studies. Color flow Doppler imaging is a dependable alternative to angiography. An algorithm for the initial assessment of neck injuries is suggested.

No abstract

The objective of this study was to identify the patterns of injury in urban free-fall victims so as to establish guidelines of management. This prospective study at an academic level I trauma center included 187 consecutive patients who presented to our trauma center during a 9-month period (September 1994 to June 1995) after a fall from a height of 5 to 70 feet. Only three falls were from heights of more than 40 feet. Of these patients, 116 (65.1%) suffered significant trauma. Fractures were the most common injuries, accounting for 76.2% of all injuries. Spinal fractures were detected in 37 patients and were associated with neurologic deficits in 7. Intraabdominal injuries occurred in 11 patients, requiring operative intervention in 9 of them. Solid organ lacerations prevailed, but small bowel perforation and bladder rupture were present in one case each. A significant retroperitoneal hematoma was detected in only one case and a thoracic aortic rupture in one more. The height of the fall correlated highly with the incidence of intoxication and severity of injury, the need for operation, the length of hospitalization, and mortality. Most urban free-falls occur from moderate heights. The spinal column is frequently injured and therefore should be thoroughly assessed clinically and radiographically in all fall victims. Intraabdominal organ injuries are much more common than retroperitoneal ones. Thus the abdominal cavity should be the primary target of aggressive workup in hemodynamically unstable patients. The height of the fall is a good predictor of injury severity and outcome prognosis.