Changing incidence and management of penetrating neck injuries in the South East London trauma centre

Abstract

INTRODUCTIONA total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King’s College Hospital over a 3-year period in the 1980s. In April 2010 King’s College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years.METHODSData were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment.RESULTSThe past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality.CONCLUSIONSThe increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.

Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre

“…It is recommended that the patient be observed for 24 to 48 hours, and a soft-tissue lateral X-ray of the neck should be considered. 2,5,12 Within our series, external exploration of the neck was justified in only 9 (41 per cent) of the 22 patients who underwent this exploration, if applying the guidelines proposed by Burgess et al However, the majority of these cases presented in the early years of the study period, reflecting an older management strategy that favoured operative exploration of injuries which penetrated the platysma.…”

“…However, an increase in interpersonal, urban and gang violence has led to an increase in the number of patients presenting to the accident and emergency department (A&E) with penetrating neck trauma. 1,2 In England and Wales in the year (to June) 2012, there were almost 30 000 offences recorded that involved a knife or sharp instrument. 3 Furthermore, it is estimated that 10 per cent of all trauma patients have a penetrating neck injury.…”

“…[5][6][7] The management of penetrating neck trauma is highly variable, being influenced by region and local experience. 1,2,5 The development of modern medical, anaesthetic and surgical practice, along with military experience (most recently in Iraq and Afghanistan), has resulted in improved patient outcomes and more effective management. 6,8 For example, literature on pre-hospital care of penetrating neck trauma suggests that the use of a rigid neck collar may actually have a detrimental effect on management.…”

“…The literature shows multiple reports of negative findings for neck explorations, sometimes over 50 per cent. 2,[13][14][15][16][17][18][19] Burgess et al published an evidence-based review of how such low velocity penetrating neck trauma should be managed. 5 According to these authors, urgent surgical exploration is required for: urgent airway injury, including airway compromise, massive subcutaneous emphysema and air bubbling through the wound; or signs of major vascular injury, including profuse active bleeding, refractory shock, rapidly expanding haematoma and evolving stroke.…”

Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test.

“…Different characteristics of neck trauma are usually related to the social and cultural conditions of the population. Penetrating neck injuries are more likely to occur in highly populated areas where there is more interpersonal violence and more gun and knife crime between young men (3). Additionally, the rise of global terrorism and continuing wars in the Middle East has perpetuated head and neck injuries in the civilian population leading to elevated morbidity and mortality rates.…”