Management of Stab Wound to Anterior Neck with Hypoxemia
Cricothyroidotomy should be performed first in a patient with anterior neck stab wound who is alert but has severe hypoxemia (oxygen saturation 82%). 1
Rationale for Immediate Airway Intervention
- In penetrating anterior neck trauma with significant hypoxemia (SpO2 82%), securing a definitive airway takes absolute priority over oxygen administration alone, as the airway may be compromised due to direct injury, expanding hematoma, or tissue edema 1
- Despite the patient being alert (indicating current cerebral perfusion), the critically low oxygen saturation requires immediate intervention to prevent rapid deterioration 1
- Cricothyroidotomy is preferred as the first intervention because it:
- Provides definitive airway control below the likely level of injury
- Bypasses potential upper airway obstruction
- Allows immediate oxygenation and ventilation 1
Why Not Other Options?
- Oxygen mask alone (option A) would be insufficient as it does not address the potential airway compromise, which is likely causing the severe hypoxemia 2, 1
- Endotracheal intubation (option C) may be difficult or impossible due to anatomical distortion, bleeding, or direct tracheal injury from the stab wound 1
- Tracheostomy (option D) takes longer to perform than cricothyroidotomy and requires more extensive dissection, making it less suitable for this emergency situation 1
Post-Cricothyroidotomy Management
- After securing the airway via cricothyroidotomy, administer high-flow oxygen through the cricothyroidotomy tube 1
- Target oxygen saturation of 94-98% as recommended for trauma patients 2
- Obtain arterial blood gas measurements to guide ongoing oxygen therapy 2
- Arrange urgent surgical exploration of the neck wound 1
Special Considerations
- If cricothyroidotomy is technically impossible or contraindicated, attempt bag-valve-mask ventilation with high-flow oxygen at 15 L/min while preparing for surgical airway 1
- Monitor for tension pneumothorax, which can accompany penetrating neck trauma and worsen hypoxemia 1
- For patients with penetrating trauma, the British Thoracic Society recommends initiating treatment with a reservoir mask at 15 L/min and aiming at a saturation range of 94-98% until the airway is secured 2
- In cases of major trauma, high-concentration oxygen should be administered from a reservoir mask at 15 L/min pending availability of satisfactory blood gas measurements or until the airway is secured by surgical intervention 2
Pitfalls to Avoid
- Delaying definitive airway management while attempting less invasive measures can lead to complete airway obstruction and death 1, 3
- Failing to recognize that a patient with penetrating neck trauma may deteriorate rapidly despite initially appearing stable 3
- Attempting endotracheal intubation without preparation for surgical airway can waste critical time if the intubation is unsuccessful due to distorted anatomy 1
- Focusing solely on oxygen administration without addressing the underlying airway compromise will not resolve the hypoxemia 2, 1