“Done got stabbed doc”

May 18, 2012

Chest XR, Neck, Trauma, XR


“Done got stabbed doc”

Chief Complaint:  “I done got stabbed in the neck doc.”  (He actually said this…I can’t make this stuff up).

This gentleman was “roughing up” his wife when she decided she had enough and stabbed him in the neck with a kitchen knife.  He had a “Zone I” area laceration just above the clavicle on the right side roughly 4cm lateral to the sternal notch.

Here is his Chest X-ray:

This patient has…

A penetrating laryngeal injury.

The plain radiograph of his chest shows extensive subcutaneous emphysema that can be seen on his X-ray in the neck region.  This, combined with the physical exam finding of a hoarse voice confirmed the diagnosis of a laryngeal injury.  After a CT of the neck with IV contrast showed no vascular injury, he was taken to the OR where trauma used a nasopharyngoscope to reveal a small puncture in the larynx just lateral to the vocal cords.  He was treated conservatively, had an esophagram showing no injury, and was discharged on hospital day #3 with no complications.  He did not undergo exploratory neck dissection.  

Management of penetrating neck injuries can cause acute stress for  both ED physicians and trauma surgeons.  First, take your own pulse.  Next, remember your ABCs!  The first and foremost evaluation the ED physician needs to do is to assess whether this individual needs a plastic tube in their trachea.  Indications for immediate intubation or surgical airway include (1):

1.  Altered mental status, unstable vital signs

2.  Obstruction or expanding hematoma

3.  Copious secretions or blood

4.  Acute respiratory distress

In this case, the guy was literally asking in a hoarse voice for “dilaudid” while updating his Facebook page from his phone.

Once you’ve established that your patient doesn’t need an acute airway, relax, decide what to do next.  I refer you to several references in the management of penetrating neck injury:

References

1.  Baron BJ.  “Trauma to the Neck” (Chapter 257).  In: Tintinalli et al.   Emergency Medicine:  A Comprehensive Study Guide.  7e.  2011.

2.  Burgess, CA, Dale OT, Almeyda R, and Corbridge RJ.  An Evidence Based Review of the Assessment and Management of Penetrating Neck Trauma.  Clin Otolaryngol.  2012, 37: 44-52.

Author:  Russell Jones, M.D.

Imaging Study:  Chest Xray

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EMREMS: Radiology in Emergency Medicine

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