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 drowsiness?

Management of Stab Wound to Neck with Hematoma, Weak Carotid Pulse, and Drowsiness

Immediate surgical exploration (option A) is the recommended management for a patient with a stab wound to the neck below the angle of mandible presenting with hematoma, weak carotid pulse, and drowsiness. 1

Rationale for Immediate Surgical Exploration

• The combination of hematoma, weak carotid pulse, and drowsiness represents "hard signs" of vascular injury requiring immediate operative intervention without preoperative imaging 1
• Drowsiness indicates cerebral ischemia due to compromised carotid blood flow, representing a neurological emergency that requires immediate intervention 1
• A 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 1
• Delaying surgical exploration in patients with hard signs of vascular injury significantly increases mortality and morbidity 1, 2

Management Algorithm

1. Initial Stabilization

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

2. Immediate Surgical Exploration

   • Proceed directly to the operating room for neck exploration 1
   • The location below the mandibular angle corresponds to Zone II of the neck, which is accessible for surgical exploration 1, 4

3. Surgical Approach

   • Use an oblique cervical incision for adequate exposure 4
   • Gain proximal vascular control in the neck before exploring the hematoma 5
   • Perform appropriate arterial repair rather than ligation when possible, especially in patients with neurological symptoms 4

Why CT or Angiography is Not First-Line

• While CT angiography (option B) and conventional angiography (option C) have high sensitivity and specificity for vascular injuries, they should not delay definitive treatment in unstable patients with hard signs 1
• The risk of delayed treatment outweighs the benefits of imaging in patients with hard signs of vascular injury 1, 2
• The combination of hematoma and neurological deterioration indicates active bleeding with compromised cerebral perfusion, requiring immediate surgical control 1

Important Considerations

• Patients with penetrating neck wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than ligation of the injured carotid artery 4
• Operative repairs for injuries in zone II include all the options used with peripheral vascular injuries 4
• The mortality rate for untreated carotid artery injuries is reported to be 18.4% 1

Common Pitfalls to Avoid

• Delaying surgical exploration to obtain imaging studies in patients with hard signs of vascular injury 1
• 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 1