Complex penetrating cervical wound

A 24-year-old man presented to the trauma center with gunshot wounds to the neck, chest and back. The patient was awake but lethargic with a heart rate of 120 beats per minute, a systolic blood pressure of 80 mm Hg and absent breath sounds on the right. He was noted to have an expanding hematoma of the left neck under a gunshot wound, a gunshot wound to the left chest at the level of the nipple, a gunshot wound overlying the left scapula, and a fourth gunshot wound penetrating the left deltoid muscle. The most appropriate first step in management of this patient in addition to resuscitation is: 1. Foreign body X-ray series. 2. Left anterolateral thoracotomy. 3. Orotracheal intubation/right thoracostomy tube. 4. Pressure dressing to left neck. The patient underwent orotracheal intubation, insertion of a right thoracostomy tube, and transfusion of blood through large bore intravenous catheters. A foreign body series demonstrated a deep sulcus sign on the left with a pulmonary contusion, a retained bullet in the region of the right shoulder and several bullet fragments in the left shoulder (figure 1). Subsequently, a left-sided thoracostomy tube was inserted with drainage of a hemothorax. After transfusion of 3 units of packed red blood cells and 3 units of plasma, the patient’s systolic blood pressure increased to 120 mm Hg and his heart rate decreased to 80 beats per minute. As the patient’s cervical hematoma was stable, a CT scan of the neck and chest was performed with a single load of intravenous contrast. The CT scan demonstrated an intimal defect in the left common carotid artery and a trajectory highly concerning for esophageal perforation (figure 2). Figure 1 Paper clips mark gunshot wounds. Red arrows are anterior and blue arrows are posterior. Figure 2 CT scan demonstrating carotid (red arrow) and esophageal (blue arrow) injuries. The most …