Puncture wound without foreign body of trachea
ICD-10 S11.023 is a billable code used to indicate a diagnosis of puncture wound without foreign body of trachea.
A puncture wound of the trachea is a specific type of injury characterized by a breach in the tracheal wall, typically caused by a sharp object or trauma. This injury can occur in various contexts, including accidents, assaults, or medical procedures. Unlike lacerations, puncture wounds are defined by their small entry points and can lead to significant complications, such as airway obstruction, pneumothorax, or subcutaneous emphysema. The absence of a foreign body indicates that the wound is not complicated by retained objects, which can further complicate management. Clinical evaluation often involves imaging studies, such as CT scans, to assess the extent of the injury and any associated damage to surrounding structures. Management typically requires airway stabilization, potential surgical intervention, and careful monitoring for complications. Prompt recognition and treatment are crucial to prevent life-threatening outcomes.
Documentation must include a detailed account of the injury mechanism, initial assessment findings, and any interventions performed.
Trauma cases involving stab wounds or accidental punctures during medical procedures.
Emergency providers should ensure that all relevant details are captured to support the diagnosis and any associated procedures.
Operative reports should detail the surgical approach, findings, and any repairs made to the trachea.
Surgical intervention for tracheal repair following a puncture wound.
Surgeons must document the extent of the injury and any complications encountered during the procedure.
Used in cases of airway compromise due to tracheal injury.
Document the indication for intubation and any complications.
Emergency medicine providers must ensure clear documentation of the need for intubation.
A puncture wound is characterized by a small entry point caused by a sharp object, while a laceration involves a tear or cut in the skin or tissue, often with a larger opening.
