What is the first step in managing a patient with a stab wound to the anterior neck who is alert but has hypoxemia (oxygen saturation 82%)?

Management of Anterior Neck Stab Wound with Hypoxemia

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

Rationale for Immediate Cricothyroidotomy

• An oxygen saturation of 82% in a trauma patient with an anterior neck wound indicates imminent respiratory failure that requires immediate intervention 1
• Standard endotracheal intubation may be impossible or dangerous in this scenario due to:
  • Distorted neck anatomy from the stab wound
  • Risk of converting partial airway obstruction to complete obstruction
  • Potential for worsening bleeding or injury 1
• Cricothyroidotomy provides the fastest and most direct route to secure the airway in this life-threatening situation

Cricothyroidotomy Procedure

1. Identify the cricothyroid membrane (between thyroid and cricoid cartilages)
2. Make a horizontal incision through skin and membrane
3. Insert an appropriate tube (typically 5-6 mm internal diameter)
4. Confirm placement by observing chest rise and auscultation
5. Secure the tube to prevent dislodgement 1

Post-Airway Management

After securing the airway via cricothyroidotomy:

1. Apply high-flow oxygen via the cricothyroidotomy tube
2. Target oxygen saturation of 94-98% 2, 1
3. Control bleeding from the neck wound
4. Assess for vascular injury (carotid, jugular)
5. Obtain imaging studies once the patient is stabilized
6. Arrange immediate surgical consultation for definitive management 1

Critical Considerations

• Speed is essential - hypoxemia at 82% indicates critical respiratory compromise
• Minimal manipulation of the neck is crucial to prevent worsening injury
• Major vessels in the neck may be injured and require immediate attention after the airway is secured
• Continuous monitoring of vital signs and oxygen saturation is mandatory 1

Common Pitfalls to Avoid

1. Delayed intervention: Waiting for imaging or other diagnostic studies before securing the airway can lead to complete airway obstruction and death
2. Attempting standard intubation: This may worsen the injury or convert partial obstruction to complete obstruction
3. Inadequate oxygenation: After securing the airway, ensure high-flow oxygen delivery
4. Missing associated injuries: Once the airway is secured, complete a thorough trauma assessment 1

This approach aligns with emergency airway management guidelines for trauma patients with compromised airways and severe hypoxemia, where the priority is to rapidly establish a secure airway to prevent mortality from respiratory failure.