What is the management of a mid neck stab wound in pediatrics?

Management of Mid Neck Stab Wound in Pediatrics

The management of pediatric mid neck stab wounds requires immediate assessment of airway patency, with prompt establishment of a secure airway being the highest priority to prevent mortality. 1

Initial Assessment and Stabilization

Airway Management

• Assess airway patency immediately by looking, listening, and feeling for airflow at both the mouth/nose and the wound site
• Apply high-flow oxygen to the face and wound site if available
• Position the child appropriately:
  • Children under 2 years: neutral position
  • Children over 2 years: slight extension ("sniffing position")
  • Consider placing a rolled towel under shoulders to improve airway access 1

Signs of Airway Compromise

• Stridor
• Accessory muscle use
• Tracheal tug
• Sternal, sub-costal, and intercostal recession
• Agitation, restlessness, or distress
• Cyanosis or low oxygen saturations 1

Immediate Interventions for Airway Obstruction

1. If the child is breathing spontaneously, deliver oxygen to the patent airway (mouth or wound)
2. If breathing is inadequate:
   • Attempt rescue breaths via the most patent airway (face or stoma)
   • Use waveform capnography if available to confirm ventilation 1
   • For ventilation via stoma, apply pediatric facemask or supraglottic airway device over the wound 1

Wound Exploration and Management

Primary Survey

• Control active hemorrhage with direct pressure
• Assess for "hard signs" of vascular or aerodigestive injury:
  • Active hemorrhage
  • Expanding hematoma
  • Airway compromise
  • Hemodynamic instability
  • Subcutaneous emphysema/crepitus 2

Hemodynamic Stabilization

• Establish large-bore IV access
• Initiate crystalloid fluid resuscitation
• Monitor vital signs continuously
• Prepare for blood transfusion if needed 2

Wound Exploration

• Avoid exploration near the inferior costal margin due to high risk of intercostal vessel damage 1
• For mid-neck wounds, careful exploration should be performed by experienced personnel in an operating room setting
• Assess for tracheal injury, which may not be immediately apparent 3

Definitive Management

Imaging

• For stable patients: CT angiography of the neck is first-line imaging
  • Sensitivity 90-100% for vascular injuries
  • Specificity 98.6-100% for vascular injuries 2
• Evaluate for:
  • Vascular injury
  • Aerodigestive tract injury
  • Pneumomediastinum (suggests tracheal penetration) 3, 4

Surgical Management

• Unstable patients require immediate surgical exploration
• Stable patients with positive imaging findings may require:
  • Tracheal repair for large ruptures
  • Vascular repair for vessel injuries
  • Esophageal repair for penetrating injuries 2, 5

Non-operative Management

• Consider for hemodynamically stable patients without evidence of major vessel or aerodigestive tract injury 1
• Requires capability for intensive monitoring and immediate surgical intervention if needed 1

Special Considerations in Pediatrics

Tracheostomy Management

If the child has a pre-existing tracheostomy:

1. Assess tube patency first
2. If obstructed, remove the tube (consider it a foreign body)
3. For emergency tube change:
   • First attempt: same size tube with dedicated obturator
   • Second attempt: tube one half-size smaller
   • Third attempt: use suction catheter as guide with tube one half-size smaller 1
4. After insertion, confirm placement by passing a suction catheter 1

Tetanus Prophylaxis

• Administer tetanus prophylaxis based on immunization status:
  • For uncertain or incomplete immunization: Tetanus Immune Globulin (TIG) 250 units IM plus tetanus toxoid
  • For children <7 years: TIG dosage may be calculated by body weight (4.0 units/kg) 6

Complications and Pitfalls

Common Pitfalls

• Underestimating seemingly minor wounds: Even apparently trivial neck injuries can have serious consequences 5
• Delayed recognition of tracheal injury: Can lead to pneumomediastinum and respiratory compromise 3
• Inadequate exploration: Missing deep injuries that aren't immediately apparent 5
• Improper airway management: Attempting ventilation through a displaced tracheostomy tube can cause subcutaneous emphysema 1

Potential Complications

• Pneumocephalus (air in cranial cavity) 4
• Vascular injury leading to hemorrhage or stroke
• Tracheal/esophageal injury leading to mediastinitis
• Infection
• Airway compromise

Follow-up Care

• Monitor for delayed complications
• Psychiatric and social service evaluation for intentional injuries 7
• Wound care education for parents/caregivers
• Follow-up with appropriate specialists based on injuries identified

Remember that pediatric neck stab wounds, even those that appear minor, require thorough evaluation as they can involve critical structures with life-threatening consequences.