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

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

Rationale for Immediate Cricothyroidotomy

• Anterior neck trauma with severe hypoxemia represents a true airway emergency
• Delayed transition to a front of neck airway (FONA) can lead to significant morbidity and mortality 1
• The British Thoracic Society and American Thoracic Society specifically recommend cricothyroidotomy as the first intervention in patients with anterior neck trauma and severe hypoxemia 1
• A reservoir mask at 15 L/min is insufficient as a first step with an unstable airway from neck trauma 1

Why Other Options Are Not Appropriate First Steps

• Oxygen mask: While oxygen therapy is important, it would be insufficient in this scenario as the primary issue is likely airway compromise from the stab wound, not just hypoxemia 1
• Endotracheal intubation: This may be difficult or impossible due to potential distortion of anatomy from the stab wound and could worsen the injury
• Tracheostomy: Takes too long to perform in an emergency situation compared to cricothyroidotomy

Procedure for Cricothyroidotomy

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

Post-Procedure Management

• After securing the airway via cricothyroidotomy, target oxygen saturation should be 94-98% via high-flow oxygen 1
• Continue monitoring:
  • Oxygen saturation
  • Respiratory rate
  • Heart rate
  • Arterial blood gases 30-60 minutes after intervention 1

Common Pitfalls to Avoid

• Delayed action: Hesitation in performing cricothyroidotomy can lead to preventable morbidity and mortality 1
• Task fixation: Focusing on less critical interventions while the patient continues to deteriorate
• Inadequate preparation: Ensure cricothyroidotomy equipment is immediately available at the bedside 1

Remember that in this scenario, the patient's severe hypoxemia (82%) in the context of an anterior neck stab wound represents an immediate threat to life that requires the fastest and most reliable method to secure the airway, which is cricothyroidotomy.