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Shotgun wound to manubrium sterni, right anterior neck, and right supraclavicular area
  1. David V Feliciano
  1. Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr David V Feliciano; davidfelicianomd{at}gmail.com

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History

A 38-year-old man presented to the trauma center with a close-range oblique shotgun wound to the manubrium sterni, right anterior neck, and right supraclavicular area.

Examination

The patient was alert and responsive on arrival. His initial vital signs included a heart rate of 110 beats per minute, a systolic blood pressure of 100 mm Hg, and a respiratory rate of 20 per minute. There was a 12 cm wide by 4 cm high rectangular avulsion of the skin extending from the medial left infraclavicular area across the manubrium sterni and the lower anterior neck. At the right end of the defect was a deep hole 3 cm in diameter which had been stuffed with dry mesh gauze by an emergency medical technician at the scene prior to transport to the trauma center. Unfortunately, the gauze was saturated with arterial blood.

Question

The most appropriate first step in the management of this patient in addition to resuscitation is:

  1. Transfemoral insertion of a resuscitative endovascular balloon occlusion of the aorta device.

  2. Bilateral anterolateral thoracotomy at the third interspace.

  3. Endotracheal intubation.

  4. Cricothyroidotomy.

Management

There was no clear-cut air leak from the deep anterior cervical hole. Therefore, endotracheal intubation was performed in the emergency room, followed by an anterior X-ray of the neck and upper chest (figure 1). Manual compression was applied to the blood-soaked gauze in the wound in the lower anterior neck as the patient was moved to the operating room.

Figure 1

An X-ray of the lower neck and upper chest demonstrating the distribution of the shotgun pellets.

The patient’s upper extremities were placed at his sides, and a transverse shoulder roll was used to hyperextend the neck. Findings on physical examination (left-to-right oblique shotgun wound with deep hole in the suprasternal area) and X-ray (pellets concentrated in the medial right supraclavicular area) were reviewed prior to deciding on …

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