What is the first step in managing a patient with a stab wound in the anterior neck who is alert but has hypoxemia (low oxygen saturation) of 82% on pulse oximetry (pulse oximeter)?

Management of Anterior Neck Stab Wound with Hypoxemia

For a patient with a stab wound to the anterior neck who is alert but has an oxygen saturation of 82%, immediate cricothyroidotomy is the first intervention required to secure the airway and prevent mortality.

Rationale for Cricothyroidotomy

The patient presents with:

• Anterior neck stab wound
• Severe hypoxemia (SpO2 82%)
• Patient is still alert (suggesting compensatory mechanisms are still functioning)

This clinical scenario represents an immediate life-threatening emergency with potential for:

1. Complete airway obstruction due to:
   • Expanding hematoma
   • Direct airway injury
   • Edema formation
2. Rapid deterioration of respiratory status

Why Cricothyroidotomy is the First Step:

• Severity of hypoxemia: SpO2 of 82% indicates severe hypoxemia requiring immediate airway intervention 1
• Anterior neck trauma: Standard endotracheal intubation may be impossible or dangerous due to:
  • Distorted anatomy
  • Risk of converting partial airway obstruction to complete obstruction
  • Potential for worsening bleeding or injury

Why Other Options Are Not Appropriate First Steps:

• Oxygen mask (Option A): While oxygen therapy is indicated for hypoxemia, in this case it would be insufficient as the primary problem is airway compromise, not just oxygenation 2. The British Thoracic Society guidelines recommend high-flow oxygen for critically ill patients, but this assumes a patent airway.

• Tracheostomy (Option B): Takes too much time and requires surgical expertise and equipment not immediately available in an emergency situation.

• Endotracheal intubation (Option C): High risk of failure and complications in anterior neck trauma; may be impossible due to distorted anatomy, bleeding, or direct airway injury.

Procedure Algorithm

1. Immediate cricothyroidotomy:

   • Identify cricothyroid membrane (between thyroid and cricoid cartilages)
   • Make a horizontal incision through skin and membrane
   • Insert appropriate tube
   • Confirm placement and secure tube

2. After airway is secured:

   • Apply high-flow oxygen via the cricothyroidotomy tube
   • Target SpO2 94-98% as recommended by British Thoracic Society guidelines 2

3. Subsequent management:

   • Control bleeding
   • Assess for vascular injury
   • Obtain imaging (once stable)
   • Definitive surgical repair

Important Considerations

• Speed is critical: Hypoxemia of 82% in the context of neck trauma indicates imminent respiratory failure
• Monitoring: Continuous monitoring of vital signs and oxygen saturation is essential 1
• Definitive care: Arrange for immediate surgical consultation for definitive management of the neck wound

Pitfalls to Avoid

• Delay in securing airway: Attempting less invasive measures first may lead to complete airway obstruction and death
• Excessive manipulation: Minimal manipulation of the neck is crucial to prevent worsening injury
• Overlooking vascular injury: Major vessels in the neck may be injured and require immediate attention after the airway is secured

Remember that in this scenario, securing the airway takes absolute priority over all other interventions to prevent mortality.