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Difficulty: EasyTrauma and Burns

Following an assault, a 29-year-old woman is evaluated in the emergency department for a deep stab wound to the right side of her neck. On arrival, she is confused and diaphoretic. Her blood pressure is 80/40 mmHg and her pulse is 130/min. Physical examination reveals an actively expanding, pulsatile hematoma in the right anterior cervical triangle. There is a continuous stream of bright red blood oozing through the applied pressure dressing. The patient's airway remains patent and breath sounds are bilateral. Which of the following is the most appropriate next step in management?

  1. Immediate surgical exploration of the neckAnswer
  2. B
    Computed tomography angiography of the cervical vessels
  3. C
    Duplex ultrasonography of the carotid arteries
  4. D
    Local wound exploration in the emergency department
  5. E
    Observation with serial hematocrit measurements

Answer

The correct answer is immediate surgical exploration of the neck.
The correct action is immediate surgical exploration of the neck. This patient has sustained penetrating neck trauma and is in hemorrhagic shock. Furthermore, she exhibits classic 'hard signs' of severe vascular injury: an actively expanding, pulsatile hematoma and continuous brisk bleeding. In the context of penetrating trauma, the presence of hemodynamic instability or any hard signs of aerodigestive or vascular injury serves as an absolute, immediate indication for operative exploration and hemorrhage control.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and presenting vital signs.
The patient is in hemorrhagic shock, evidenced by hypotension (80/40 mmHg), tachycardia (130/min), and altered mental status (confusion, diaphoresis).
Determining hemodynamic stability dictates whether the patient can undergo diagnostic imaging or must proceed directly to the operating room.
2
Evaluate the neck wound for 'hard signs' of vascular or aerodigestive tract injury.
The patient has an expanding, pulsatile hematoma and active, continuous bleeding that is refractory to local pressure.
Hard signs of injury in penetrating neck trauma are absolute indications for surgical intervention.
3
Select the most appropriate next step based on the clinical findings.
Immediate surgical exploration of the neck is required.
Hemodynamically unstable patients with penetrating trauma and hard signs of vascular injury must bypass all imaging and undergo emergent operative exploration.

Key Concept

Patients with penetrating neck trauma who exhibit hemodynamic instability or 'hard signs' of vascular injury (such as an expanding/pulsatile hematoma, active severe bleeding, thrill/bruit, or absent pulse) require immediate surgical exploration.
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Topics

Trauma and Burns

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