What is the management for a stab wound to the neck?

Management of Penetrating Neck Trauma

All penetrating neck injuries should be immediately transported to a trauma center, and management depends on hemodynamic stability and presence of "hard signs" versus "soft signs" of injury. 1, 2

Initial Assessment and Stabilization

Hemodynamically unstable patients or those with hard signs require immediate surgical exploration without imaging. 2, 3

Hard Signs Requiring Immediate Operative Exploration:

• Active hemorrhage or pulsatile hematoma 2
• Expanding hematoma (indicates active bleeding threatening airway or causing exsanguination) 2
• Hemodynamic instability 2, 3
• Airway compromise or air bubbling from wound 2
• Hemoptysis (suggests tracheal or major vascular injury) 2
• Pneumothorax (indicates aerodigestive tract injury) 2
• Dysphonia (suggests laryngeal or recurrent laryngeal nerve injury) 2
• Unilateral upper-extremity pulse deficit or bruit/thrill 2
• Massive hematemesis 2

Delaying surgical exploration in patients with hard signs significantly increases mortality. 2

Soft Signs Allowing Time for Imaging:

• Nonpulsatile/nonexpanding hematoma 2
• Dysphagia (may indicate esophageal or pharyngeal injury) 2
• Minor subcutaneous emphysema 3
• Venous oozing 2

Management Algorithm for Stable Patients

The American College of Radiology recommends a "no-zone" approach focusing on clinical signs rather than anatomic zones alone. 2, 4

Imaging Protocol:

• CT angiography (CTA) is first-line imaging for stable patients with soft signs, with 90-100% sensitivity and 98.6-100% specificity for vascular injuries. 2, 3
• CTA should be obtained regardless of injury zone in stable patients 3, 4
• CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 3
• Initial plain radiographs may identify radio-opaque foreign bodies, soft-tissue swelling, airway compromise, fractures, and subcutaneous emphysema before CTA 3

Additional Imaging Based on Specific Concerns:

• CT esophagography or barium swallow for suspected esophageal injury (sensitivity 95-100%) 2, 3
• Conventional catheter angiography reserved for equivocal CTA findings with concerning foreign body trajectory 2, 3
• MRI for evaluating spinal cord injury, traumatic disk injury, and ligamentous injury in stable patients without metallic foreign bodies 3

Airway Management Considerations

For patients requiring intubation with suspected cervical spine injury, use manual in-line stabilization with removal of the anterior cervical collar during intubation. 3

• Employ rapid sequence induction with direct laryngoscopy and gum elastic bougie without Sellick maneuver 3
• Early spine immobilization is essential for any patient with suspected spinal cord injury 3
• Maintain systolic blood pressure >110 mmHg in patients with suspected spinal cord injury to reduce mortality 3

Selective Management Outcomes

Selective management based on clinical signs is safe and superior to mandatory exploration of all penetrating neck injuries. 2, 4

• In stable patients without hard signs who undergo observation, delayed exploration is required in only 0.5% of cases 5
• Nontherapeutic exploration rates are approximately 16% when immediate exploration is performed 5
• Length of stay is significantly shorter for observed patients (1.5 days) compared to those undergoing exploration (8.0 days) or negative exploration (5.1 days) 5

Zone-Specific Considerations

While the no-zone approach is preferred, zone 1 injuries (below cricoid cartilage) carry the highest mortality (12-20%) and often require midline sternotomy combined with cervicotomy for vascular control in unstable patients. 6

Critical Pitfalls to Avoid

• Never delay surgical exploration in patients with hard signs of vascular or aerodigestive injury 2, 3
• Never fail to maintain cervical spine immobilization during initial assessment 3
• Never rely solely on physical examination without appropriate imaging in stable patients 3
• Never neglect to consider potential end-organ injury, particularly to the brain, when cervical vascular injury is present 3
• Never assume drains provide adequate protection—clot formation may prevent drainage and provide false reassurance 1