What is the most appropriate management for a patient with a stab wound to the mid-left anterior neck, active bleeding, and an expanding hematoma, presenting with hypotension, tachycardia, and tachypnea?

Immediate Surgical Exploration

This patient requires immediate surgical exploration without any preoperative imaging studies. 1, 2

Clinical Rationale

This patient presents with hard signs of vascular injury that mandate emergent operative intervention:

• Active bleeding from a penetrating neck wound indicates ongoing hemorrhage requiring immediate control 1, 2
• Expanding hematoma represents active bleeding that could rapidly compromise the airway or lead to exsanguination 2, 3
• Hemodynamic instability (BP 96/54, HR 108) indicates hemorrhagic shock requiring immediate bleeding control 4

The combination of these findings represents a life-threatening emergency where delaying surgical exploration significantly increases mortality 1, 2. The American College of Radiology explicitly recommends immediate operative intervention without preoperative imaging for patients presenting with hard signs including hematoma and hemodynamic instability 1.

Why Other Options Are Inappropriate

Local Wound Exploration (Option B)

• Contraindicated in the presence of active bleeding and expanding hematoma 2
• Local exploration cannot adequately control deep vascular injuries lateral to the larynx, which likely involves major vessels (carotid artery, internal jugular vein) 3, 5
• The expanding hematoma indicates the injury extends beyond superficial structures 3

Esophagram (Option A) and Ultrasonography (Option C)

• Any imaging delays definitive treatment in hemodynamically unstable patients with hard signs 1, 2
• The mortality rate increases significantly with delays in surgical intervention for patients arriving in hemorrhagic shock 4, 6
• While CT angiography has excellent sensitivity (90-100%) for vascular injuries, it should never delay surgical intervention in unstable patients 1, 2, 6

Immediate Management Algorithm

1. Airway management: Secure the airway while maintaining cervical spine precautions, as expanding hematomas can rapidly compromise the airway 1, 3

2. Resuscitation: Establish large-bore IV access and begin fluid resuscitation with crystalloids, targeting systolic BP 80-100 mmHg until bleeding is controlled 4

3. Activate massive transfusion protocol for ongoing hemorrhage 6

4. Proceed directly to the operating room for neck exploration without imaging 1, 2, 6

5. Prepare for potential sternotomy: Stab wounds lateral to the larynx in the mid-neck may involve zone I vessels requiring median sternotomy for proximal vascular control 5

Critical Pitfalls to Avoid

• Do not obtain imaging studies in patients with hard signs and hemodynamic instability—this significantly increases mortality 1, 2
• Do not underestimate superficial-appearing wounds: Even small external wounds can cause life-threatening vascular injuries with expanding hematomas 7
• Do not perform local wound exploration for penetrating injuries with active bleeding and expanding hematomas, as this provides inadequate exposure for vascular control 2, 3

The correct answer is D: Surgical exploration.