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

Management of Anterior Neck Stab Wound with Hypoxemia

In a patient with an anterior neck stab wound who is alert but has oxygen saturation of 82%, cricothyroidotomy should be performed as the first intervention to secure the airway and prevent mortality. 1

Rationale for Emergency Surgical Airway

• Anterior neck trauma with severe hypoxemia (SpO2 82%) represents a critical airway emergency that requires immediate intervention
• The American Thoracic Society and British Thoracic Society specifically recommend cricothyroidotomy as the first-line intervention in patients with anterior neck trauma and severe hypoxemia 1
• Delayed transition to a front of neck airway (FONA) can lead to significant morbidity and mortality in trauma patients 1

Why Other Options Are Not Appropriate First Steps

1. Oxygen Mask

   • While oxygen therapy is important, a reservoir mask at 15 L/min is insufficient as a first step with an unstable airway from neck trauma 1
   • Studies show limitations in the efficacy of oxygen masks with reservoir bags, particularly in patients with severe respiratory failure 2
   • The anterior neck wound likely compromises normal airway anatomy, making oxygen mask therapy ineffective as a primary intervention

2. Endotracheal Intubation

   • Conventional intubation may be difficult or impossible due to:
     • Potential distortion of airway anatomy from the stab wound
     • Risk of complete airway obstruction during intubation attempts
     • Possible hematoma or subcutaneous emphysema complicating visualization

3. Tracheostomy

   • While effective, tracheostomy is a more complex and time-consuming procedure
   • Not recommended as the first-line emergency surgical airway in this acute scenario
   • Cricothyroidotomy is faster and more appropriate for immediate airway access

Cricothyroidotomy Procedure

The procedure should follow these steps as recommended by Advanced Trauma Life Support guidelines 1:

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

Post-Cricothyroidotomy Management

After securing the airway via cricothyroidotomy:

• Provide high-flow oxygen to achieve target SpO₂ of 94-98% 1
• Implement continuous monitoring of oxygen saturation, respiratory rate, and heart rate 1
• Arrange for definitive airway management and surgical exploration of the neck wound
• Position the patient in a semi-recumbent position (30-45° head elevation) to reduce work of breathing 1

Common Pitfalls to Avoid

• Delayed action: Recognize that clinical signs of failed ventilation may be unreliable; don't wait for profound hypoxemia before establishing an emergency airway 1
• Task fixation: Avoid getting fixated on less effective interventions when a surgical airway is clearly needed 1
• Inadequate preparation: Ensure cricothyroidotomy equipment is immediately available at the bedside for trauma patients 1

The evidence strongly supports immediate cricothyroidotomy as the first intervention for this patient with anterior neck trauma and severe hypoxemia to secure the airway and prevent mortality.