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Zorluk: OrtaCardiothoracic and Vascular Surgery

A 2424-year-old man is brought to the emergency department after sustaining a stab wound to the left anterior neck, midway between the cricoid cartilage and the angle of the mandible. He is agitated and has a hoarse voice. His respiratory rate is 2828/min and oxygen saturation is 92%92\% on room air. Blood pressure is 85/5085/50 mm Hg, and heart rate is 125125/min. Physical examination reveals a large, rapidly expanding hematoma on the left side of the neck with overlying pulsatile bleeding. Arrange the following management steps in the most appropriate chronological sequence for this patient.

  1. 1Secure the airway via rapid sequence endotracheal intubation.
  2. 2Transport the patient immediately to the operating room without preoperative vascular imaging.
  3. 3Obtain proximal and distal vascular control of the injured carotid artery.
  4. 4Perform definitive vascular repair using primary suture or interposition grafting.

Cevap

The correct sequence begins with securing the airway, followed by immediate transport to the operating room due to hard signs of vascular injury. In the operating room, proximal and distal vascular control must be achieved before performing definitive surgical repair.
The correct sequence prioritizes the ABCs of trauma and fundamental vascular surgery principles. The expanding hematoma and hoarseness indicate impending airway loss, requiring immediate intubation. The presence of hemodynamic instability and pulsatile bleeding constitute 'hard signs' of vascular injury in Zone II of the neck. Such patients must be taken directly to the operating room for neck exploration; delaying for imaging increases mortality. Intraoperatively, the surgical team must first obtain proximal and distal control of the carotid artery to prevent exsanguination before opening the hematoma to perform the definitive vascular repair.

Adım Adım Çözüm

1
Identify impending airway compromise and secure the airway.
The airway is protected from external compression by the rapidly expanding hematoma.
Airway patency is the highest priority in trauma resuscitation, especially in Zone II neck injuries with compressive symptoms.
2
Recognize hard signs of vascular injury and proceed directly to the operating room.
Avoidance of life-threatening delays associated with advanced imaging.
Hemodynamic instability and an expanding, pulsatile hematoma represent surgical emergencies that require immediate operative intervention.
3
Obtain proximal and distal vascular control surgically.
Blood flow to the injured arterial segment is temporarily halted.
Attempting to explore or repair a actively bleeding vessel without prior control often leads to massive, uncontrollable exsanguination.
4
Execute definitive vascular repair.
The vascular integrity is restored.
With hemorrhage safely controlled, the arterial defect can be properly assessed and repaired with sutures or a graft.

Anahtar Kavram

Management of penetrating neck trauma with hard signs of vascular injury requires immediate airway stabilization followed by emergent surgical exploration (without prior imaging), utilizing the vascular surgery principle of securing proximal and distal control before definitive repair.
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Cardiothoracic and Vascular Surgery

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