What is the best management approach for an 8-year-old boy with a stab wound to the middle and lateral side of the neck, who is stable but has an expanding hematoma (collection of blood outside of blood vessels)?

Management of Expanding Neck Hematoma in a Pediatric Patient with Stab Wound

Immediate surgical exploration is the required management for an 8-year-old boy with a stab wound to the neck presenting with an expanding hematoma, even if the patient is currently stable. 1

Rationale for Surgical Exploration

An expanding hematoma in the neck following penetrating trauma indicates ongoing bleeding that requires immediate control. This is a surgical emergency for several reasons:

• The American College of Surgeons Advanced Trauma Life Support guidelines specifically recommend immediate surgical intervention for expanding hematomas, as delays in controlling bleeding significantly increase mortality 1
• European guidelines (Grade 1B) state that patients with neck stab wounds who present with progressive or expanding hematomas require immediate surgical exploration 2, 1
• Conservative management is contraindicated for expanding hematomas as this indicates active bleeding that won't resolve spontaneously 1
• In pediatric patients with expanding hematomas, the same principles of management apply, though surgical approach may need modification based on anatomy 1

Initial Management Prior to Surgery

While preparing for surgical exploration:

1. Airway management: Secure the airway with endotracheal intubation if there are signs of airway compromise, as expanding hematomas can rapidly compress and obstruct the airway 1

2. Bleeding control: Apply direct local compression to limit external bleeding while preparing for surgery 1

3. Volume resuscitation: Restore organ perfusion with appropriate fluid resuscitation, but avoid excessive fluid administration that might increase bleeding 2

4. Blood product preparation: Activate massive transfusion protocol if needed and ensure blood products are available 2

Why Not Other Options?

• Embolization (Option B): While angioembolization may be appropriate for some vascular injuries, it is not the first-line treatment for an expanding hematoma in a pediatric patient with a neck stab wound. Surgical exploration provides direct access to control bleeding and assess other potential injuries 2, 1

• Angiography (Option C): Diagnostic angiography alone is insufficient when an expanding hematoma is present. The patient requires immediate intervention to control bleeding, not just diagnosis 2, 1

• Conservative management (Option D): This approach is explicitly contraindicated for expanding hematomas as they represent active, ongoing bleeding that requires intervention 1

Special Considerations for Pediatric Patients

• Pediatric patients with expanding hematomas require the same principles of management as adults, though surgical approach may need modification based on smaller anatomy 1

• The location of the stab wound (middle and lateral side of neck) may influence the surgical approach, particularly if the injury is below the cricoid cartilage (zone 1), which might require a combined approach with sternotomy 1

Post-Surgical Management

After successful surgical control:

• Monitor for delayed complications including spinal infarction, which has been reported following hypovolemic shock from neck stab wounds 1

• Ensure appropriate antibiotic coverage if indicated by wound contamination 1

• Monitor for coagulopathy which can develop in the setting of significant hemorrhage 2

• Initiate venous thromboprophylaxis once bleeding has been controlled, as patients rapidly develop a prothrombotic state 2

In summary, while the patient is currently stable, the expanding hematoma represents a surgical emergency requiring immediate exploration and control of bleeding sources to prevent airway compromise, exsanguination, and death.