What is the management for a patient with a stab wound to the neck below the angle of the mandible, presenting with a hematoma, weak carotid pulse, and signs of neurological deterioration such as drowsiness?

Management of Stab Wound to the Neck Below the Mandibular Angle with Hematoma, Weak Carotid Pulse, and Drowsiness

Immediate surgical exploration is the appropriate management for a patient with a stab wound to the neck below the mandibular angle presenting with hematoma, weak carotid pulse, and drowsiness. 1

Clinical Assessment and Decision Making

• The patient presents with multiple "hard signs" of vascular injury including hematoma, weak carotid pulse, and neurological deterioration (drowsiness), which mandate immediate operative intervention without preoperative imaging 1
• Hard signs of vascular injury are associated with unstable or potentially unstable patients and require immediate surgical exploration to prevent further neurological deterioration and death 1
• Drowsiness indicates cerebral ischemia due to compromised carotid blood flow, representing a neurological emergency requiring immediate intervention 1
• The weak carotid pulse suggests partial occlusion or active bleeding from the carotid artery, which can rapidly progress to complete occlusion and stroke if not addressed promptly 2

Rationale for Immediate Surgical Exploration

• Delaying surgical exploration in patients with hard signs of vascular injury (hematoma, weak pulse, neurological changes) significantly increases mortality and morbidity 3
• The combination of hematoma and neurological deterioration indicates active bleeding with compromised cerebral perfusion, requiring immediate surgical control 4
• The mortality rate for untreated carotid artery injuries is high (18.4%), with the major cause of death related to neurological damage associated with carotid injury and shock 5
• While imaging studies like CTA have high sensitivity and specificity for vascular injuries, they should not delay definitive treatment in unstable patients with hard signs 1

Management Algorithm

1. Initial Stabilization:

   • Secure airway while maintaining cervical spine immobilization 3
   • Establish large-bore IV access and begin fluid resuscitation 1
   • Apply direct pressure to control external bleeding if present 1

2. Immediate Surgical Exploration:

   • Proceed directly to the operating room for neck exploration 1
   • Obtain proximal and distal vascular control of the carotid artery 4
   • Assess the extent of vascular injury and perform appropriate repair 6

3. Vascular Repair Options:

   • Primary repair for clean lacerations involving <50% of vessel circumference 4
   • Interposition grafting for more extensive injuries 7
   • Ligation may be considered in cases with severe neurological deficit already present 7

Important Considerations

• While CT angiography is the first-line imaging modality for stable patients with neck injuries (sensitivity 90-100%, specificity 98.6-100%), it should not delay surgical intervention in patients with hard signs 3
• Patients with hard signs who are hemodynamically stable may benefit from CTA, but this patient's drowsiness indicates neurological compromise requiring immediate intervention 1
• The location of the injury (below the mandibular angle) corresponds to Zone II of the neck, which is accessible for surgical exploration 1
• Angiography may be valuable postoperatively to assess the adequacy of repair but should not delay initial surgical management in this unstable patient 5

Common Pitfalls to Avoid

• Delaying surgical exploration to obtain imaging studies in patients with hard signs of vascular injury 3
• Underestimating the significance of drowsiness as a sign of cerebral ischemia requiring immediate intervention 1
• Failing to recognize that a weak carotid pulse and hematoma represent impending complete vascular occlusion or rupture 2
• Relying solely on physical examination without appropriate surgical exploration in patients with hard signs 3