What is the recommended incision for a patient with a stab wound to zone III, presenting with profuse bleeding and subcutaneous (subcutaneous emphysema) emphysema?

From the Research

For a patient with a stab wound to zone III of the neck presenting with profuse bleeding and subcutaneous emphysema, the recommended incision is a median sternotomy with possible extension to a supraclavicular incision, as this approach provides optimal exposure to the proximal great vessels and distal internal carotid artery, which are likely involved given the zone III location. The presence of subcutaneous emphysema suggests aerodigestive tract injury, possibly involving the pharynx or proximal esophagus, which requires adequate visualization 1. Before making the incision, the surgical team should ensure adequate resuscitation, establish a secure airway (potentially through a surgical airway if orotracheal intubation is challenging), and have blood products readily available.

The sternotomy approach allows control of the proximal vessels at the thoracic outlet before exploring the distal injury, following the principle of proximal and distal control of vascular injuries. This extensive exposure is justified by the life-threatening nature of zone III injuries, which have limited accessibility through standard cervical incisions and carry high mortality if not adequately exposed and repaired. The use of a median sternotomy with possible extension to a supraclavicular incision is supported by the most recent and highest quality study available, which highlights the importance of adequate exposure and control in managing such injuries 2.

Key considerations in managing this patient include:

• Ensuring adequate resuscitation and establishing a secure airway
• Controlling proximal and distal vessels to prevent further bleeding
• Adequately visualizing the aerodigestive tract to assess for injury
• Being prepared for potential complications, such as pneumothorax or pneumomediastinum, as described in the literature 3, 4, 5.

Overall, the recommended approach prioritizes optimal exposure and control, while also considering the potential for complications and the need for careful management to minimize morbidity and mortality.