What is the recommended management for a patient with a neck stab wound and signs of hematoma expansion?

Management of Neck Stab Wounds with Progressive/Expanding Hematoma

Immediate surgical exploration is the recommended management for patients with neck stab wounds who present with progressive or expanding hematoma, especially when accompanied by hemodynamic instability. 1, 2

Initial Assessment

When evaluating a patient with a penetrating neck injury, rapidly assess for:

• "Hard signs" of vascular or aerodigestive injury:

  • Active hemorrhage
  • Pulsatile or expanding hematoma
  • Hemodynamic instability (low BP, elevated pulse)

• "Soft signs" of injury:

  • Nonpulsatile/nonexpanding hematoma
  • Venous oozing
  • Dysphagia

Management Algorithm

For Hemodynamically Unstable Patients (Case 1: Low BP, elevated pulse with progressive hematoma)

1. Immediate surgical exploration without preoperative imaging 1, 2

   • This is the definitive management for patients with expanding hematoma and hemodynamic instability
   • Do not delay for imaging studies in unstable patients

2. Airway management

   • Secure airway with endotracheal intubation if there are signs of airway compromise 1
   • Avoid hyperventilation unless signs of cerebral herniation are present 1

3. Bleeding control

   • Apply direct local compression to limit external bleeding while preparing for surgery 1
   • Avoid blind probing or clamping of bleeding vessels in the neck as this may damage uninvolved structures 3, 4

For Stable Patients with Expanding Hematoma (Case 2: 8-year-old boy with expanding hematoma but stable vitals)

1. Immediate surgical exploration is still the recommended management 1, 2

   • An expanding hematoma, even in a hemodynamically stable patient, is a hard sign that requires immediate intervention

2. Rationale for surgical exploration over other options:

   • European guidelines strongly recommend (Grade 1B) that patients with hemorrhagic shock and an identified source of bleeding undergo immediate bleeding control procedures 1
   • The American College of Surgeons Advanced Trauma Life Support guidelines classify expanding hematomas as requiring immediate surgical intervention 1
   • Delays in controlling bleeding significantly increase mortality 1

Why Not Other Options?

• Angiography: While useful for stable patients without hard signs, it delays definitive treatment in patients with expanding hematomas 2, 5

• Embolization: May be considered after angiography for select cases, but not as first-line treatment when an expanding hematoma is present 5

• Conservative management: Not appropriate for expanding hematomas as this indicates ongoing bleeding that requires immediate control 1

Special Considerations

• Anatomical location matters: For injuries below the cricoid cartilage (zone 1), a midline sternotomy combined with cervicotomy may be necessary for adequate exposure and bleeding control 6

• Pediatric patients: The same principles apply to children with expanding hematomas, though surgical approach may need modification based on anatomy 1

• Post-surgical monitoring: After successful surgical control, monitor for delayed complications including spinal infarction, which has been reported following hypovolemic shock from neck stab wounds 7

Pitfalls to Avoid

• Delayed intervention: The most common cause of death in penetrating neck injuries is poor initial control of bleeding 4

• Blind clamping: Never blindly clamp bleeding vessels in the neck as this can damage adjacent structures, particularly nerves 4

• Over-reliance on imaging: While CT angiography is valuable for stable patients without hard signs, it should not delay surgical intervention when hard signs like expanding hematoma are present 2, 5