What is the appropriate immediate management for a patient with a throat laceration (cut)?

Immediate Management of Throat Laceration (Cut Throat Injury)

Airway management is the absolute priority in throat laceration injuries, and the tracheal cannula should be inserted directly through the opening in the injured larynx immediately to maintain airway patency, rather than attempting oral intubation or delaying with compression alone. 1

Initial Resuscitation and Airway Control

Immediate Airway Establishment

• Insert a tracheal tube directly through the wound opening if the larynx or trachea is exposed, as this provides the fastest and most reliable airway access in severe injuries 1, 2
• If the wound does not expose the airway or if direct insertion fails, perform emergency tracheostomy below the level of injury 3, 4, 5
• Endotracheal intubation via the mouth may be attempted only if the upper airway anatomy is intact and the patient is stable enough, but this is rarely feasible in severe injuries 3
• Apply high-flow oxygen to both the face and the wound site simultaneously, requiring two separate oxygen sources 6

Critical Pitfall to Avoid

The most dangerous error is attempting to manage the airway with simple compression alone—one case series documented dyspnea developing when emergency physicians only used gauze compression rather than establishing a definitive airway 1. This delay can be fatal.

Hemorrhage Control and Resuscitation

• Control active bleeding with direct pressure while simultaneously establishing the airway 3, 5
• Begin immediate blood replacement for patients with significant hemorrhage 3
• Patients with severe hemorrhage and/or aspiration have the highest mortality risk—three deaths occurred from these complications in one series 3

Assessment of Injury Extent

Stable Patients

• Perform enhanced neck CT to assess the full extent of injury in hemodynamically stable patients without "hard signs" (active bleeding, expanding hematoma, airway compromise) 1
• Triple endoscopy (esophagoscopy, laryngoscopy, and bronchoscopy) should be performed once the airway is secured, as injury to one structure raises suspicion for damage to adjacent organs 6
• Use low-flow insufflation with CO2 rather than air during endoscopy to minimize mediastinal contamination 6

Unstable Patients

• Proceed immediately to surgical exploration for patients with hemodynamic instability, obvious contrast extravasation, or severe sepsis 6, 1
• Intraoperative endoscopy can rule out esophageal perforation in patients rushed to the operating room 6

Surgical Repair Principles

• Repair injured structures in layers after establishing airway control 3
• For cervical esophageal injuries, direct repair should be attempted whenever feasible; if not possible, perform esophagostomy with cervical drainage 6
• Insert a nasogastric or Ryle's tube for esophageal injuries to decompress the upper GI tract 3, 1
• Buttress repairs with viable tissue and provide adequate drainage to prevent complications like tracheo-esophageal fistula 6

Post-Operative Management

Immediate Care

• Keep patients nil per os (NPO) 6
• Initiate broad-spectrum antibiotic coverage 6
• Begin enteral feeding via gastric tube or total parenteral nutrition early 6, 1
• Monitor for subcutaneous emphysema, which indicates tube displacement or tracheal wall injury 7

Monitoring Requirements

• Continuous pulse oximetry to evaluate oxygenation 7
• Continuous waveform capnography to confirm adequate ventilation and tube patency 6, 7
• Close observation for mediastinitis signs: severe sore throat, deep cervical pain, chest pain, dysphagia, fever, and crepitus 6

Long-Term Considerations

• Post-operative endoscopy identifies nerve injuries and stenosis problems 3
• Laryngo-tracheal stenosis is a significant long-term morbidity, occurring in a substantial proportion of patients 4
• Decannulation may be possible in approximately 75% of patients who survive the initial injury 3
• Psychiatric evaluation and therapy is critical, as most injuries are suicidal attempts 3, 1, 5

Zone-Specific Considerations

Most injuries occur in Zone II (between the cricoid cartilage and angle of mandible), accounting for approximately 73% of cases 3. Zone II injuries have the highest risk of involving multiple critical structures including the larynx, trachea, esophagus, and major vessels.