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

Cricothyroidotomy is the recommended first intervention for a patient with anterior neck stab wound and severe hypoxemia (oxygen saturation 82%) to secure the airway and prevent mortality. 1

Rationale for Immediate Cricothyroidotomy

• In patients 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
  • Likely to worsen bleeding or injury 1

• The American Thoracic Society and British Thoracic Society both recommend cricothyroidotomy as the first-line intervention in this scenario to secure the airway and prevent mortality 1

• Delayed transition to front of neck airway (FONA) due to procedural reluctance is a common cause of morbidity in airway crises 2

Procedure for Emergency Cricothyroidotomy

1. Identify the cricothyroid membrane
2. Make a horizontal incision
3. Insert an appropriate tube
4. Confirm placement (via waveform capnography)
5. Secure the tube 1

Why Other Options Are Not Appropriate First Steps

• Oxygen mask: While reservoir masks at 15 L/min are recommended for severe hypoxemia in stable patients, this is insufficient as a first step with an unstable airway from neck trauma 1

• Endotracheal intubation: High risk of failure and worsening the situation due to distorted anatomy and potential for complete airway obstruction 1

• Tracheostomy: Takes too long in an emergency situation compared to cricothyroidotomy

Post-Cricothyroidotomy Management

• Target oxygen saturation after securing the airway should be 94-98% via high-flow oxygen 1
• Ensure adequate neuromuscular blockade if needed 2
• Continue oxygenation attempts during the transition to cricothyroidotomy 2
• Confirm successful ventilation with waveform capnography 2

Important Considerations

• Recognition of failed ventilation may be difficult with clinical signs being unreliable; waveform capnography is the definitive monitor for confirming alveolar ventilation 2
• There is no specific threshold oxygen saturation for transition to FONA, but establishing an emergency airway before profound hypoxemia occurs is desirable 2
• An explicit declaration of failure ("This is a can't intubate, can't oxygenate situation") facilitates practical and psychological preparation for FONA 2

Common Pitfalls to Avoid

• Delayed action: The most common error is hesitation in performing cricothyroidotomy, which leads to preventable morbidity and mortality 2
• Task fixation: Continuing with failed techniques instead of rapidly progressing to definitive airway management 2
• Inadequate preparation: Ensure cricothyroidotomy equipment is immediately available at the bedside 2

In this life-threatening scenario with anterior neck trauma and severe hypoxemia, cricothyroidotomy provides the fastest and most reliable means of establishing a definitive airway, preventing further deterioration and potential cardiac arrest.