A bilateral emergency room thoracotomy for a stab neck

Case history: A 26 year old male presented to casualty with a single stab wound neck.

Clinical findings: Zone I Neck stab to right supraclavicular region, actively bleeding

Investigation/ Results: eFAST - right hemopneumothorax,ABG - severe metabolic acidosis

Diagnosis: Right subclavian vein injury,Grade IV Right superior lung lobe laceration,2nd intercostal artery laceration

Therapy and Pregressions: A Foley catheter inserted into the actively bleeding stab wound to tamponade. The patient had a GCS of 9/15, the airway was patent but threatened, decision was made to intubate. The initial blood pressure was normal, E-fast positive for right-sided hemopneumothorax, and a right intercostal drain was placed with no output. The second BP was 55/40 and the decision was made to perform bilateral emergency thoracotomies. Left-sided thoracotomy was used to cross-clamped the aorta and from the right-sided thoracotomy a subclavian vein injury was identified and two Foley catheters inserted into the wound tract via thoracotomy to further tamponade the bleeding. A grade IV lung laceration was sutured. The patient was resuscitated in the emergency department with blood products, started on inotropes, and rapidly transported to the operating theatre. Neck exploration was performed via a supra- and infraclavicular incisions. The subclavian artery was identified and proximal and distal control established. The subclavian vein was exposed. Initially, primary repair was attempted; however, after visualising the full extent of the injury, vein ligation was indicated. An injury to the 2nd intercostal artery was sutured and ligated

Comments:The initial treatment of unstable patients with penetrating neck injuries ranges from foley catheter tamponade, haemostatic suture to left or right anterolateral thoracotomy. The indications for performing the emergency thoracotomy depend on multiple factors

References: J Trauma. 79(1):159–173, July 2015, South African Journal of Surgery 2023;61(3)

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