Which of the following is the most appropriate next step in management?
A young man sustains a gunshot wound to the base of his neck. He was shot point blank with a .38 caliber revolver. The entrance wound is above the left clavicle, below the level of the cricoid cartilage, and just lateral to the sternomastoid muscle. The exit wound is just above the spinous process of the right scapula. He has normal breath sounds on both sides, is awake and alert, is talking with a normal tone of voice, is neurologically intact, and is hemodynamically stable. Portable x-ray films of the neck and chest took in the emergency department showed some air in the tissues of the lower neck, but are otherwise non-diagnostic.
A. Observation for several hours B. CT scan of the lower neck and upper chest C. Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration D. Immediate surgical exploration of the lower neck through a collar incision E. Immediate surgical exploration of the upper chest through a median sternotomy
Imagine a young man getting shot. This would cause all sorts of medical issues depending on where the bullet entered into the young man’s body as well as the path it took through the man’s body. Even though someone is shot, some people remain awake and others do not.
The doctor will first analyze the young man to determine where the bullet entered and then conduct some x-rays to determine which organs it hit. If there was air in the tissues of the lower neck, there would be certain steps to do.
An angiogram would be conducted to determine if the heart was affected. Then three other procedures would be conducted to determine if other organs were affected before going to surgery. These would be esophagogram, esophagoscopy and bronchoscopy.
Angiogram, esophagogram, esophagoscopy, and bronchoscopy prior to surgical exploration -gunshot wounds to the base of the neck need exploratory surgery, but the exact approach and incision are determined by a more accurate knowledge of the location and extent of the injuries. thus, if time permits, diagnostic studies should precede surgical intervention. the major vessels, the tracheobronchial tree, and the esophagus are the potential targets that have to be investigated. observation (choice a) might be appropriate for a stab wound in a completely asymptomatic patient. in gunshot wounds, we have to expect that injuries will exist, and they should not be neglected waiting for overt clinical signs. ct scan (choice b) has done wonders for our assessment of closed head injuries and blunt abdominal trauma, but it is not the study that would tell us what has happened to the major vessels, the esophagus, or the tracheobronchial tree in a gunshot wound. immediate surgical exploration, either through the neck or the chest, or in combination, might be forced by a rapidly deteriorating situation. in the absence of such imperative, a decision to open the neck (choice d) or the chest (choice e) is premature at this point