What is the initial management for a patient presenting with a penetrating stab wound to the neck?

Initial Management of Penetrating Neck Stab Wound

Immediately assess for hard signs of injury that mandate direct surgical exploration without any imaging—these include expanding hematoma, active hemorrhage, pulsatile hematoma, hemodynamic instability, dysphonia, hemoptysis, pneumothorax, air bubbling from the wound, or airway compromise. 1, 2

Immediate Stabilization

Hemorrhage Control

• Apply direct local compression to control active bleeding as the first-line measure 2
• Place an occlusive dressing over the wound with direct pressure, but never apply circumferential bandages around the neck as this can compromise the airway 2
• For persistent bleeding, consider inserting a Foley catheter directly into the wound tract and inflate the balloon to achieve tamponade 2
• Stabilize any impaled objects with bulky dressings; only remove if obstructing the airway 2

Airway Management

• Perform endotracheal intubation without delay if airway obstruction, altered consciousness, hypoventilation, or hypoxemia are present 2
• Use manual in-line stabilization with removal of the anterior cervical collar during intubation if cervical spine injury is suspected 2
• Consider rapid sequence induction with videolaryngoscopy in time-critical situations 2

Hemodynamic Resuscitation

• Establish IV access and administer crystalloid fluids to maintain systolic blood pressure >90 mmHg in hemorrhagic shock 2
• Target systolic blood pressure >110 mmHg if spinal cord injury is suspected 2, 3
• Initiate massive transfusion protocol as needed for ongoing hemorrhage 3

Decision Algorithm: Hard Signs vs Soft Signs

Hard Signs → Immediate Surgical Exploration (NO IMAGING)

Proceed directly to the operating room without any imaging studies, as mortality increases significantly with delays in surgical intervention. 1, 2

Hard signs include:

• Expanding hematoma 1
• Active hemorrhage or pulsatile hematoma 1
• Hemodynamic instability 1, 3
• Dysphonia (laryngeal/recurrent laryngeal nerve injury) 1
• Hemoptysis (tracheal or major vascular injury) 1
• Pneumothorax (aerodigestive tract injury) 1
• Air bubbling in the wound 1
• Bruit/thrill or unilateral upper-extremity pulse deficit 1
• Massive hematemesis 1

Soft Signs → CT Angiography First (Selective Management)

For hemodynamically stable patients without hard signs, obtain imaging before deciding on surgical exploration 1, 2:

• Dysphagia (possible esophageal/pharyngeal injury) 1
• Nonpulsatile/nonexpanding hematoma 1
• Venous oozing 1
• Subcutaneous emphysema 1

Imaging Protocol for Stable Patients with Soft Signs

• CT angiography (CTA) is first-line imaging with 90-100% sensitivity and 98.6-100% specificity for vascular injuries 1, 2, 3
• CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 2, 3
• Add CT esophagography or water-soluble contrast swallow if esophageal injury is suspected (sensitivity 95-100%) 2, 3
• Reserve catheter angiography for equivocal CTA findings or when endovascular intervention is planned 2

Modern "No-Zone" Approach

The American College of Radiology recommends focusing on clinical signs rather than anatomic zones alone for managing penetrating neck trauma. 1, 2, 3

• Clinical signs, not anatomic zone, determine the need for immediate exploration 3
• All wounds penetrating deep to the platysma warrant surgical exploration if hard signs are present 2
• 74% of hemodynamically stable patients with hard signs who received CTA avoided surgical neck exploration through selective management 2

Critical Pitfalls to Avoid

• Never delay surgical exploration in patients with hard signs to obtain imaging—mortality increases significantly with delays 1, 2
• Never apply circumferential neck bandages as they can compromise the airway 2
• Never rely solely on physical examination without appropriate imaging in stable patients with soft signs 2
• Do not fail to maintain cervical spine immobilization during initial assessment and airway management 2
• During surgical exploration, perform systematic examination of all structures, as multiple injuries from a single external wound can occur at different depths along the stab trajectory 4

Surgical Considerations

• Penetrating neck injuries place vital cardiopulmonary, vascular, and neurologic systems at risk and often require skills not available at every hospital 5
• Early subspecialty involvement is essential given complex anatomy, including otolaryngology, vascular surgery, neurosurgery, and plastic surgery 3
• For zone 1 injuries (below cricoid) with hemodynamic instability or active bleeding, urgent midline sternotomy combined with cervicotomy provides optimal hemorrhage control 6