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 Hematoma in Pediatric Neck Stab Wound

Immediate surgical exploration is the recommended 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

Initial Assessment and Stabilization

• Control obvious bleeding points with direct pressure while preparing for surgery
• Secure airway if there are signs of compromise (though not mentioned in this case)
• Establish large-bore IV access for fluid resuscitation
• Collect baseline blood samples including FBC, coagulation studies, and cross-match
• Activate massive transfusion protocol if needed 2
• Administer high FiO2 and actively warm the patient 2

Rationale for Surgical Exploration

The European guidelines (Grade 1B) and American College of Surgeons Advanced Trauma Life Support guidelines strongly recommend immediate surgical exploration for patients with neck stab wounds who present with expanding hematomas 1. This is particularly important because:

1. An expanding hematoma indicates ongoing bleeding that requires immediate control
2. Delays in controlling bleeding significantly increase mortality 1
3. The presence of an expanding hematoma is considered a "hard sign" of vascular injury requiring immediate intervention
4. Pediatric patients with expanding hematomas follow the same management principles as adults, though surgical approach may need modification based on anatomy 1

Why Other Options Are Not Appropriate

• Embolization (Option B): Not appropriate as 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 1.

• Angiography (Option C): While CT angiography has high diagnostic value for stable patients (sensitivity 90-100%, specificity 98.6-100% for vascular injuries), it is not appropriate as the initial management for an expanding hematoma, which requires immediate surgical control 1.

• Conservative management (Option D): Absolutely contraindicated in the presence of an expanding hematoma, which indicates ongoing hemorrhage requiring immediate intervention 1.

Surgical Considerations

• The approach will depend on the exact location of the wound (middle and lateral neck)
• Injuries below the cricoid cartilage (zone 1) may require a midline sternotomy combined with cervicotomy for adequate exposure 1
• Uncontrolled clamping of vessels should be avoided to prevent damage to uninvolved structures, especially nerves 3

Post-Surgical Management

• Monitor for coagulopathy which can develop following significant hemorrhage
• Initiate venous thromboprophylaxis once bleeding has been controlled
• Monitor for delayed complications including spinal infarction
• Consider antibiotic therapy only if signs of infection develop 1

Pitfalls to Avoid

• Delaying surgical intervention in the presence of an expanding hematoma, even if the patient appears stable
• Excessive fluid administration that might increase bleeding
• Blind clamping of bleeding vessels in the neck, which can damage nerves and other structures
• Focusing only on vascular injuries while missing potential aerodigestive tract injuries

The evidence clearly supports immediate surgical exploration (Option A) as the definitive management for this pediatric patient with a neck stab wound and expanding hematoma.