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## Complete Summary

#### GUIDELINE TITLE

Clinical practice guidelines: penetrating neck trauma.

#### BIBLIOGRAPHIC SOURCE(S)

Tisherman SA, Bokhari F, Collier B, Ebert J, Holevar M, Cumming J, Kurek
S, Leon S, Rhee P. Clinical practice guidelines: penetrating neck
trauma. Chicago (IL): Eastern Association for the Surgery of Trauma
(EAST); 2008. 52 p. \[126 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Penetrating wounds of the Zone II region of the neck that penetrate the
platysma

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Critical Care\
Emergency Medicine\
Pulmonary Medicine\
Surgery\
Thoracic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To answer the following questions regarding the management of
penetrating injuries to Zone II of the neck that penetrate the platysma:

-   Is operative management mandatory or is selective non-operative
    management appropriate?

-   Is physical examination adequate to rule out injuries to vascular
    structures or the aerodigestive tract?

-   Can duplex ultrasonography (US) or Computed tomography (CT)
    angiography rule out an arterial injury in patients with no hard
    signs of vascular injury on physical examination, thereby making
    arteriography unnecessary?

-   How should specific vascular injuries be managed?

-   Are both contrast studies (barium or gastrograffin swallow) and
    esophagoscope needed to safely rule out esophageal injury?

-   Is there a need for immobilization of the cervical spine?

#### TARGET POPULATION

Patients with penetrating neck trauma of the Zone II region

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Assessment**

1.  Selective operative management and mandatory exploration (of
    penetrating injuries to Zone II)

2.  Diagnosis of arterial injury

    -   Computed tomography (CT) angiography

    -   Duplex ultrasonography

    -   Arteriography

3.  Diagnosis of esophageal injury

    -   Contrast esophagography

    -   Esophagoscopy

4.  Physical exam including auscultation of the carotid arteries

**Management**

1.  Management of specific vascular injuries

    -   Angiographic approaches to vertebral artery injuries

    -   Ligation of the jugular vein (for complex injuries or unstable
        patients)

2.  Cervical spine immobilization in select patients

#### MAJOR OUTCOMES CONSIDERED

-   Mortality

-   Missed injury rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The process utilized by this committee was developed by the Practice
Management Guidelines Committee of the Eastern Association for the
Surgery of Trauma ([http://www.east.org](http://www.east.org/portal/)).

The committee agreed upon the questions to be considered. Literature for
review included the following terms: human, trauma patients,
penetrating, and neck; specific structures were also searched (larynx,
trachea, esophagus, carotid artery, and jugular vein). Medline and
EMBASE were searched from 1966 to 2006.

#### NUMBER OF SOURCE DOCUMENTS

145

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Class I**: Prospective, randomized, double blinded study

**Class II**: Prospective, randomized, non-blinded trial

**Class III**: Retrospective series, meta-analysis

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An evidentiary table (see Table 1 in the original guideline document)
was constructed using the 145 references that were identified: Class I,
2 references; Class II, 26 references; and Class III, 105 references.
Twelve of the references could not be classified.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Recommendations were made on the basis of the studies included in the
evidentiary table (see Table 1 of the original guideline document).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Level 1**: Usually based on class I data, were meant to be
convincingly justifiable on scientific evidence alone.

**Level 2**: Usually supported by class I and II data, were to be
reasonably justifiable by available scientific evidence and strongly
supported by expert opinion.

**Level 3**: Usually based on Class II and III data, were to be made
when adequate scientific evidence is lacking, but the recommendation is
widely supported by available data and expert opinion.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of recommendation (1-3) and classes of evidence (I-III) are
defined at the end of the \"Major Recommendations\" field.

A.  **Selective workup -- operation vs. selective non-operative
    management**

> **Level 1**
>
> Selective operative management and mandatory exploration of
> penetrating injuries to Zone II of the neck are equally justified and
> safe.
>
> **Level 2**
>
> No recommendations.
>
> **Level 3**
>
> No recommendations.

B.  **Diagnosis of arterial injury**

> **Level 1**
>
> No recommendations.
>
> **Level 2**
>
> Computed tomography (CT) angiography or duplex ultrasonography can be
> used in lieu of arteriography to rule out an arterial injury in
> penetrating injuries to Zone II of the neck.
>
> **Level 3**
>
> CT of the neck (even without CT angiography) can be used to rule out a
> significant vascular injury if it demonstrates that the trajectory of
> the penetrating object is remote from vital structures. With injuries
> in proximity to vascular structures, minor vascular injuries such as
> intimal flaps may be missed.

C.  **Diagnosis of esophageal injury**

> **Level 1**
>
> No recommendations.
>
> **Level 2**
>
> Either contrast esophagography or esophagoscopy can be used to rule
> out an esophageal perforation that requires operative repair.
> Diagnostic workup should be expeditious because morbidity increases if
> repair is delayed by more than 24 hours.
>
> **Level 3**
>
> No recommendations.

D.  **Value of the physical exam**

> **Level 1**
>
> No recommendations.
>
> **Level 2**
>
> No recommendations.
>
> **Level 3**

1.  Careful physical examination, including auscultation of the carotid
    arteries, is \>95% sensitive for detecting arterial injuries that
    require repair. Given the potential morbidity of missed injuries,
    imaging is still recommended.

2.  Physical examination is inadequate to rule out injuries to the
    aerodigestive tract.

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E.  **Management of specific vascular injuries**

> **Level 1**
>
> No recommendations.
>
> **Level 2**

1.  Except for minimal intimal irregularities or small pseudoaneurysms
    without neurologic deficits, penetrating injuries to the internal
    carotid artery should be repaired, even when severe neurologic
    deficits are present.

2.  Angiographic approaches to the vertebral artery are preferred to
    operative approaches for patients with bleeding from vertebral
    artery injuries.

3.  Ligation of the jugular vein is appropriate for complex injuries or
    unstable patients.

> **Level 3**
>
> No recommendations.

F.  **Cervical Spine Immobilization**

> **Level 1**
>
> No recommendations.
>
> **Level 2**
>
> Immobilization of the cervical spine is unnecessary unless there is
> overt neurologic deficit or an adequate physical examination cannot be
> performed (e.g., the unconscious victim).
>
> **Level 3**
>
> No recommendations.

**Definitions**:

**Classes of Evidence**

**Class I**: Prospective, randomized, double blinded study

**Class II**: Prospective, randomized, non-blinded trial

**Class III**: Retrospective series, meta-analysis

**Levels of Recommendation**

**Level 1**: Usually based on class I data, were meant to be
convincingly justifiable on scientific evidence alone.

**Level 2**: Usually supported by class I and II data, were to be
reasonably justifiable by available scientific evidence and strongly
supported by expert opinion.

**Level 3**: Usually based on Class II and III data, were to be made
when adequate scientific evidence is lacking, but the recommendation is
widely supported by available data and expert opinion.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see the \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management and treatment of patients with penetrating neck
trauma

#### POTENTIAL HARMS

Complications related to management/treatment measures

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The Eastern Association for the Surgery of Trauma (EAST) is a
    multi-disciplinary professional society committed to improving the
    care of injured patients. The Ad hoc Committee for Practice
    Management Guideline Development of EAST develops and disseminates
    evidence-based information to increase the scientific knowledge
    needed to enhance patient and clinical decision-making, improve
    health care quality, and promote efficiency in the organization of
    public and private systems of health care delivery. Unless
    specifically stated otherwise, the opinions expressed and statements
    made in this publication reflect the authors\' personal observations
    and do not imply endorsement by nor official policy of the Eastern
    Association for the Surgery of Trauma.

-   \"Clinical practice guidelines are systematically developed
    statements to assist practitioner and patient decisions about
    appropriate health care for specific clinical circumstances.\"\*
    These guidelines are not fixed protocols that must be followed, but
    are intended for health care professionals and providers to
    consider. While they identify and describe generally recommended
    courses of intervention, they are not presented as a substitute for
    the advice of a physician or other knowledgeable health care
    professional or provider. Individual patients may require different
    treatments from those specified in a given guideline. Guidelines are
    not entirely inclusive or exclusive of all methods of reasonable
    care that can obtain/produce the same results. While guidelines can
    be written that take into account variations in clinical settings,
    resources, or common patient characteristics, they cannot address
    the unique needs of each patient nor the combination of resources
    available to a particular community or health care professional or
    provider. Deviations from clinical practice guidelines may be
    justified by individual circumstances. Thus, guidelines must be
    applied based on individual patient needs using professional
    judgment.

\*Institute of Medicine. Clinical practice guidelines: directions for a
new program. MJ Field and KN Lohr (eds) Washington, DC: National Academy
Press. 1990: pg 39.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Tisherman SA, Bokhari F, Collier B, Ebert J, Holevar M, Cumming J, Kurek
S, Leon S, Rhee P. Clinical practice guidelines: penetrating neck
trauma. Chicago (IL): Eastern Association for the Surgery of Trauma
(EAST); 2008. 52 p. \[126 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2008

#### GUIDELINE DEVELOPER(S)

Eastern Association for the Surgery of Trauma - Professional Association

#### SOURCE(S) OF FUNDING

Eastern Association for the Surgery of Trauma (EAST)

#### GUIDELINE COMMITTEE

EAST Practice Management Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Samuel A. Tisherman, MD; Faran Bokhari, MD; Bryan
Collier, DO; James Ebert, MD; Michele Holevar, MD; John Cumming, MD;
Stanley Kurek, DO; Stuart Leon, MD; Peter Rhee, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Eastern Association for the Surgery of Trauma (EAST) Web
site](http://www.east.org/tpg/peneneck.pdf).

Print copies: Available from the Eastern Association for the Surgery of
Trauma Guidelines, c/o William J. Bromberg, MD, FACS, Memorial Health
University Medical Center, Savannah Surgical Group, Inc., 4700 Waters
Avenue, Savannah, GA 31404; Phone: (912) 350-7412; Email:
<guidelines@east.org>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Utilizing evidence based outcome measures to develop practice
    management guidelines: a primer. 18 p. 2000. Available in Portable
    Document Format (PDF) from the [Eastern Association for the Surgery
    of Trauma (EAST) Web site](http://www.east.org/tpg/primer.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on September 12, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the Eastern Association for the Surgery of Trauma (EAST).

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/17/2008