title: Selective management of penetrating neck injuries using "no zone" approach.
abstract: BACKGROUND
  Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds.
  
  
  METHODS
  A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate.
  
  
  RESULTS
  Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%).
  
  
  CONCLUSIONS
  Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand. Electronic address: Supparerk.P@Chula.ac.th.
authors.forename: Supparerk
authors.initials: S
authors.lastname: Prichayudh
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Jirat
authors.initials: J
authors.lastname: Choadrachata-anun
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Suvit
authors.initials: S
authors.lastname: Sriussadaporn
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Rattaplee
authors.initials: R
authors.lastname: Pak-art
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Sukanya
authors.initials: S
authors.lastname: Sriussadaporn
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Kritaya
authors.initials: K
authors.lastname: Kritayakirana
authors.affiliation: Chulalongkorn University, Surgery, Rama4 rd, Bangkok, Thailand.
authors.forename: Pasurachate
authors.initials: P
authors.lastname: Samorn
mesh_terms: D000328:Adult; D000792:Angiography; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D061330:Multidetector Computed Tomography; D019838:Neck Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D018579:Patient Selection; D010808:Physical Examination / Q000379:methods*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013785:Thailand / Q000453:epidemiology; D014193:Trauma Centers / Q000706:statistics & numerical data; D014950:Wounds, Penetrating / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy
keywords: No zone approach; Penetrating neck injuries; Selective management