INTRODUCTION
Upper airway and penetrating neck traumas are uncommon representing 5%–10% of all trauma admissions, as the anatomical structure of the upper airway is protected by the mandible superiorly, sternum anteriorly and cervical spine posteriorly, making the anterior and lateral regions of the neck the most exposed to trauma. The neck contains vital structures than can be difficult to be assessed by physical examination compromising airway management. Many challenges could be faced during managing the airway in head-and-neck trauma patients and these include but are not limited to oropharyngeal and pulmonary haemorrhage or facial trauma obscuring the airway details, the possibility of a full and the risk of gastric contents aspiration, failure to establish a clear airway and the ongoing hypoxaemia which will put more stress on the operator.[1,2,3]
In our case, we report a male patient with a suicidal attempt presented to the accident and emergency (A and E) department, with a deep clear-cut laceration wound to the neck area with multiple injuries to the structures of the larynx and nearby vessels. Some structures were exposed, in particular, epiglottis, vocal cords, pre-laryngeal muscles and the internal jugular vein. The criticality of the patient has led to initiating resuscitation from securing the airways to stabilising the haemodynamics then followed by shifting the patient to the operation theatre (OT) for further evaluation and closure of the wound. The team was able to rectify all injuries sustained and then a tracheostomy was placed.
The multidisciplinary team fortunately was able to manage the patient from different aspects and treat all the issues that were faced during his hospitalisation. Presenting with a deep cut to the neck is uncommon, as most suicidal injuries to the neck present with superficial wounds. Of this, immediate action was necessary to save the life of the patient by intubation.
CASE REPORT
At 14:35, emergency medical services (EMS) had been alerted to a 25-year-old male patient who committed suicide by cutting his neck using a knife. Upon the arrival of the EMS team to the suicide scene, a huge and deep laceration was noted on the neck area measuring around half of the neck with exposure of the throat and vocal cords associated with massive bleeding from the wound [Figure 1]. Despite the patient's injury, he was breathing regularly; therefore, suctioning was done to prevent aspiration and a 15 L non-rebreather mask was applied to the neck area and immediately the patient was shifted to our facility. Table 1 demonstrates the patient's vital signs upon arrival at the A and E departments.
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Figure 1: The neck wound with exposed vascular and tracheal injuries
Table 1: Vital signs at presentation and arterial blood gases at resuscitation to accident and emergency
On arrival at the hospital at 15:07, code trauma was announced. The patient was maintaining a saturation of 97% on room air with hemodynamic stability initially except for tachycardia [Table 1], with pale skin, cold peripheries and a Glasgow Coma Scale (GCS) of 9. An anaesthesiologist on call had been called to assess the airway, the decision was to intubate the patient as GCS was dropping and airway obstruction is pending. Intubation was successfully done by an oral endotracheal tube (ETT) with a size of 7.5. Due to the exposed trachea and vocal cords, the tube went out through the wound, which was redirected through the wound to be fixed at 23 cm [Figure 2]. Simultaneously, resuscitation measures were started by the emergency physicians; therefore, two large bore intravenous cannulas were inserted and 1 L of normal saline (0.9% sodium chloride) was given followed by two units of O negative blood transfusion with 1 g of tranexamic acid. Five min later at 15:35, the patient had a cardiac arrest in the form of asystole, immediately high-quality cardiopulmonary resuscitation (CPR) started as per Advanced Cardiac Life Support (ACLS) protocol. CPR continued for 9 minutes in total, during which patient received 2 mg of epinephrine, with pulseless electrical activity rhythm throughout the resuscitation period, and fortunately at 15:44 patient achieved return of spontaneous circulation (ROSC). During resuscitation, arterial blood gas was done showing severe metabolic acidosis in addition to respiratory acidosis; hence, 100 mg sodium bicarbonate was given [Table 1].
Figure 2: The endotracheal tube in place after conventional intubation
The vascular team rushed to the emergency department to identify and stabilise bleeding from vascular injuries. On examination, it was found that the internal jugular vein was injured with some branches of the internal carotid artery; however, the internal carotid artery itself was intact. Later on, the patient was immediately shifted to the OT by the vascular surgery and ear, nose and throat teams with the general surgeon standing by.
The operation was done under general anaesthesia, where the patient was sedated ventilated and paralysed with a muscle relaxant. Further examination was done in the OT where injured structures were identified clearly, these include (a clean cut in the neck with a lacerated wound just below the hyoid cartilage with the tear of all infrahyoid muscles, thyroid cartilage completely exposed with fracture of the upper part of the left lamina, larynx open at the level of the thyrohyoid membrane with exposure of epiglottis and vocal cords and the internal jugular vein around 2 cm with arterial branches of the internal carotid artery all were injured, with a small laceration to the external jugular vein) [Figure 3].
Figure 3: Neck wound after suturing all the vascular injuries and before inserting the tracheotomy tube in the OT. OT: Operation theatre
Tracheostomy was fixed with stay sutures for ventilation and airway protection; venous repair was done by the vascular surgeon to control bleeding and achieve haemostasis. Next, the laryngeal mucosa and perichondrium were approximated, followed by the closure of pre-laryngeal muscles and the wound was closed in layers with a drain placed in situ. At last, the skin was closed, and a nasogastric tube (NGT) was placed under the vision. Nevertheless, during the surgery, he developed nasal bleeding and a pack was inserted.
Once the operation was done, the patient was haemodynamically stable, sedated and on a ventilator and shifted by the anaesthesiologist to the intensive care unit (ICU) for further management. Postoperatively, a chest radiograph and computerised tomography (CT) scan were done confirming the tracheotomy tube in place [Figure 4].
Figure 4: Chest radiograph (left) and CT (right) confirming the correct place of the tracheostomy tube. CT: Computerised tomography
In the ICU postoperative day 1, the patient developed hyperkalaemia, and the nephrology team was consulted and started on anti-hyperkalaemic measures. On post-operative day 3, the nasal pack was removed, feeding started through NGT and the sedation was also stopped to assess the level of consciousness; it was found that he was conscious but confused and agitated, for which sedation was initiated again to keep the head position flexed to ensure proper healing.
After stabilisation on the 5th day postoperatively, it was crucial to identify the cause that led to his injury to know whether it was a homicidal or suicidal attempt; therefore, a psychiatrist was involved to assess the patient and to give the proper support he needed. However, as the patient was under the effect of sedation, the assessment was inconclusive, although antipsychotics were prescribed to control the agitation.
Even when he was on antipsychotics, the patient's agitation which led him to remove the NGT that led to some difficulties in giving his antipsychotic medications, feeding and other oral medications. A trial of reinsertion was done and failed, which raised the suspicion of fistula formation between the trachea and oesophagus; therefore, an endoscopy was done that ruled out such complication, but the mucosa was bleeding easily on touch. Thus, he was kept on total parenteral nutrition feeding for some time. After that, successful reinsertion of NGT was done in the ICU.
He was reassessed by the psychiatry team again and found to have side effects from the antipsychotics that were changed later to different medications. A full assessment was done, and it was confirmed to be a suicidal attempt, which was confessed by the patient as he had a psychiatric history of depression and never completed his treatment course, with all the stressors of being unemployed added to his depression that he decided to act upon and attempt suicide.
After that, the patient was able to breathe on his own maintaining saturation on room air and able to eat. Hence, the tracheostomy tube was closed, decannulation was done and the NGT was removed after 38 days postoperatively.
After 51 days, the patient got discharged from the critical care unit to the psychiatry hospital for further management of depression.
DISCUSSION
One of the most predominant mortality causes in the middle age group in the Middle East and North Africa region is suicide with 26,000 deaths reported in 2016 which means 4.8/100,000 deaths;[4] however, self-inflicted cut-throat injuries are infrequent methods of committing suicide as the most common ways are hanging, self-immolation and poisoning.[5] Self-inflicted cut-throat injuries with exposed airways need a strong intention which is caused by low-socioeconomic status, unemployment and psychiatric illnesses like depression, etc.[6] In our case, the patient is known to have had major depression for 8 months with poor compliance to treatment regimens and being jobless for the past few months before committing suicide which acts as a stressful life event.
The neck is subdivided anatomically into three zones with zone I extending from the clavicle to the cricoid cartilage, zone II from the inferior margin of the cricoid cartilage to the angle of the mandible and zone III from the angle of the mandible to the base of the skull.[7] About 50%–80% of penetrating neck injuries involve zone II.[8]
A multidisciplinary perspective is important to outline an effective strategy for treating the patient, which needs a partnership between an anaesthesiologist, otolaryngologist, vascular surgeon, intensivist and psychiatrist.[8,9]
Once the patient reaches the emergency, a primary survey must be done thoroughly as per trauma protocol, followed by securing the airway which is the responsibility of the anaesthesiologist according to the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach. Securing the airway varies and can be done by different modalities, namely passing the ETT through the wound, direct laryngoscopy by rapid sequence induction, blind nasal intubation, fibre optic intubation or surgical airway including cricothyroidotomy and tracheostomy.[10]
The patient arrived at our facility in very critical condition with exposed and lacerated trachea and vascular bleeding, for which securing the airway by the anaesthesiologist was the first step, which was successfully done by conventional laryngoscopy intubation due to the patient's condition without the use of bougie or stylet. Nevertheless, if the patient was haemodynamically stable, fibre optic intubation would give sufficient recognition of the tracheal injuries with the easier entrance of the ETT. In addition, surgical management of the lacerated trachea could be done by immediate tracheostomy. However, it solely depends on the the physician's experience to provide a secured airway. Due to the instability in this case time was very critical and every second counts, with the experience and modalities available in the case of intubation, which has led to this decision. As there are no clear guidelines on this matter, it is advised to go with each case and decide according to the whole scenario.
In our case, we did not have the time to send the patient for any kind of imaging modality, so we decided to shift him directly to the OT for immediate exploration of the injuries. It is supported to go for further radiological investigations if the patient's condition is stable including cervical radiograph, CT scan, magnetic resonance imaging and angiography,[11] with dynamic CT scan showed better sensitivity in diagnosing associated injuries in zone II penetrating neck trauma;[12] nevertheless, radiological investigations should not delay any surgical interventions.
Taking into consideration, the haemodynamic instability, the narrow time frame that securing the airway and ventilation should be achieved and the accessibility to the tools to help intubate or secure the airway under direct vision are not the only challenges that are faced by patients. Thus, widening the scope of what to expect in patients with head-and-neck injuries can definitely improve the outcome and their mortality and morbidity. It is crucial to touch upon the various challenges that may accompany such injuries; stressing on early hypoxia and oxygen desaturation that eventually will lead to cardiopulmonary arrest, inability to identify inadequate airway, displacement of the ETT after successful initial intubation due to disturbance of anatomy or interference by the positioning of the patient and aspiration of food particles or gastric juice. Other challenges can be further classified into out-of-the-hospital settings versus in-hospital.[10]
CONCLUSION
We conclude that penetrating neck injuries such as suicidal attempts are not uncommon and need immediate intervention. It is critical to manage the airway in such neck injuries as soon as possible to protect breathing as per ABCD protocol. A multidisciplinary approach is crucial in saving the patient's life and it also showed reduced morbidity and mortality in neck trauma.
Declaration of patient consent
Unfortunately, because the patient was in an unstable psychiatric condition after having a tragic suicidal attempt, we couldn't obtain any kind of informed consent from the him, additionally, there was no family member with him, as all of his family resides back in his home country. Furthermore, patient was sent to psychiatric facility after being discharged from our hospital for inpatient admission and follow up.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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