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%)?

Emergency Management of Anterior Neck Stab Wound with Hypoxemia

Immediate cricothyroidotomy is the first intervention required for a patient with an anterior neck stab wound who is alert but has severe hypoxemia (oxygen saturation 82%) to secure the airway and prevent mortality. 1

Rationale for Cricothyroidotomy

• In a patient with anterior neck trauma and severe hypoxemia, standard endotracheal intubation may be:

  • Impossible due to distorted anatomy
  • Dangerous due to risk of converting partial airway obstruction to complete obstruction
  • Potentially worsening bleeding or injury 1

• Speed is critical in this scenario as:

  • Oxygen saturation of 82% indicates imminent respiratory failure
  • Delay in securing the airway may lead to complete airway obstruction and death
  • The cricothyroidotomy provides the fastest and most direct route to establish an airway 1

Procedure Approach

1. Identify the cricothyroid membrane
2. Make a horizontal incision through skin and membrane
3. Insert an appropriate tube
4. Confirm placement and secure the tube 1

Post-Cricothyroidotomy Management

After securing the airway via cricothyroidotomy:

• Apply high-flow oxygen via the cricothyroidotomy tube with a target oxygen saturation of 94-98% 1
• Control bleeding from the neck wound
• Assess for vascular injury
• Minimize manipulation of the neck to prevent worsening injury
• Obtain imaging studies once the patient is stabilized
• Arrange immediate surgical consultation for definitive management 1

Why Other Options Are Not Appropriate First Steps

• Oxygen mask (O mask): Ineffective in this scenario as the anterior neck wound may disrupt normal airway anatomy, and mask ventilation will not bypass the injury
• Endotracheal intubation: High risk of worsening the injury, converting partial obstruction to complete obstruction, and potentially causing more bleeding in a neck stab wound
• Tracheostomy: Takes longer to perform than cricothyroidotomy and requires more extensive dissection, which is not ideal in an emergency situation with severe hypoxemia 1

Monitoring After Airway Establishment

• Continuous monitoring of oxygen saturation, respiratory rate, and heart rate is crucial
• Regular arterial blood gas analysis to guide oxygen therapy
• Target oxygen saturation of 94-98% after securing the airway 1

Pitfalls to Avoid

• Delaying definitive airway management in a patient with anterior neck trauma and hypoxemia
• Attempting endotracheal intubation first, which may worsen the injury
• Excessive manipulation of the neck during the procedure
• Failure to identify and address associated vascular injuries after securing the airway 1