MULTIDICIPLINARY APPROACH IN PATIENT SUSPECTED LARYNGEAL INJURY WITH ACUTE PSYCHOSIS
Daniel Pramandana Lumunon1, Raihanita Zahra2
1Departement of Anesthesiology and Intensive Care Resident, Faculty of Medicine, University of Indonesia
2 Departement of Anesthesiology and Intensive Care Attending Staff, Faculty of Medicine, University of Indonesia
Introduction
Although laryngotracheal injuries are uncommon, they have a significant
fatality rate. These injuries can be either penetrating or blunt and can occur in the
supraglottic, glottic, or infraglottic regions. They are caused by penetrating
trauma, assault, attempted strangulation, near hanging, and clothesline-type
injuries.1 In one study, thirty percent of cut throat injuries were the result of
suicide.6 Airway trauma may result in acutely life-threatening airway lacerations,
obstructions, hemorrhages, and blood aspiration.2
The perioperative management of patients with laryngeal damage and
severe psychosis presents another challenge to the anesthesiologist, as both
surgery and anesthesia pose a significant risk for this patient. There are some
things that add to the risk; difficulty to interact with the patient to elicit accurate
history, to expect cooperation for evaluation, and to acquire informed consent for
anesthesia and surgery.3 Antipsychotic medications continue to be the primary
effective treatment for managing schizophrenia.5 The intraoperative findings of
the surgeon must be relayed; postoperatively, these patients must be thoroughly
followed in the critical care unit for at least the first night; and extubation must be
performed with patient cooperation to prevent further injury.
Case Presentation
Male, 32-year-old, arrived to the ER (emergency department) with probable
laryngeal damage following a suicide attempt by cutting his own throat. The
cardiothoracic surgeon diagnosed the patient with a rupture of the sternothyroid
and thyroid cartilage. After ensuring that the main assessment is secured, the
patient was referred to ENT surgeons and psychiatrist. Risperidone and
Lorazepam were administered to a patient diagnosed with paranoid
schizophrenia, bipolar disorder, and psychotic depression in order to make the
patient calmer and more cooperative for further evaluation. From the ENT, the
evaluation of the airway was assessed with right hypopharynx mucosal laceration
from the rhinopharyngolaringoscopy. The surgeon then scheduled for the patient
to undergo exploration and airway reconstruction in the operating room
(Operating Room). The patient was evaluated as having ASA (American Society of
Anaesthesiologist) physical status 3 with a possible laryngeal damage and
schizophrenia. Before beginning induction, communication is conducted in the
operation room. The selected anesthetic technique is modified RSI without cricoid
pressure, while the operator is sterile to prepare if there is an emergency condition
such as false route intubation. Preparation includes setting up a We performed the Modified RSI on the patient without cricoid pressure
videolaryngoscope, boogie, and reversal drugs such as sugamadex.
Before the patient entered the operating room, 2 mg of midazolam was
administered, and analgesia remifentanil was administered beginning at
3ng/ml via TCI with the Minto model. The patient was quite cooperative when
preoxygenation with 100% fractional oxygen was administered through the
mask. Intubation was successful on the first attempt with visualization of the
larynx using a C-MAC Videolaryngoscope. Induction began with a propofol 100
mg titration and Rocuronium 60 mg dose. The operation proceeded without
incident, and intraoperative hemodynamics were steady. The hemorrhage was
estimated to be roughly 200 ml, and the operator discovered the larynx was
lacerated and performed the surgery during the examination.
Post operatively the patient was transferred to the ICU without
extubation, adequate analgesics, antibiotics and anti-inflammatories were
given to prevent infection and tissue inflammation, antipsychotic drugs were
still given together with sedative agents, after confirming clinical signs that
there were no difficulty breathing or swallowing. So that the patient remains
compliant, extubation is performed while the patient is sedated.
Discussion
Larynx injuries account for fewer than one percent of all traumatic
injuries. They are infrequent but sometimes quite severe. After intracranial
injuries, it is the second most prevalent cause of death in individuals with head
and neck trauma. According to the Schaefer categorization method for
assessing the severity of laryngeal injuries, the patient has been diagnosed with
level group III injuries, which include extensive oedema, major mucosal
lacerations, and displaced fractures with exposed cartilage. Physical
examination begins with a comprehensive assessment of the patient's
respiratory status and hemodynamic stability (Airway, Breathing, Circulation). A
thorough examination, including flexible laryngoscopy and chest x-ray to
visualize the larynx and pahranx, is required. Acute psychosis is a challenge for
anesthesiologists since it is difficult to anticipate cooperation for examination
and treatment of acute psychotic patients. It is vital for this patient to receive
information regarding laryngeal injury damage before speeding the surgery to
make sure that there is no life threatening airway obstruction such as
respiratory distress, severe neck hematoma, major bleeding, subcutaneous neck
emphysema and stridor. After consultation with the surgeon, the presence of
blood and debris within the lumen of the airway, an injury within the airway
wall itself, or an injury outside the wall, should be regarded contraindications
for surgical or percutaneous cricothyroidotomy.2
due to the patient's psychotic diagnosis from the psychiatrist. We used a video
laryngoscope to see the vocal chord and investigate the potential injury site to
prevent additional airway passage damage. A tracheal tube should be
positioned directly above the vocal cords using the bogie as the introducer.
Therefore, if the main intubation plan fails, there is only one alternative to
prevent the condition from becoming worse: surgical tracheostomy.2The patient
was also routinely evaluated by cardiothoracic surgeons in the intensive care
unit (ICU) and the ward to assess the clinical sign of the restoration of the
laryngeal tissue and the psychiatric department to control the patient's mental
state until he was mentally stable, ensuring that he was cooperative enough
and improved his recovery. Laryngeal reconstruction takes an average of 5.6
days (3 to 10 days). Steroids, antibiotics, and anti-reflux medications should be
considered. Before extubation, a second endoscopic inspection may be
necessary to prevent problems.
Summary
In the event of cut-throat or penetrating neck injuries, the larynx,
pharynx, trachea, esophagus, and main neck vessels are susceptible to injury. A
multidisciplinary cooperation approach with a psychiatrist is necessary for the
efficient therapy of afflicted patients. The anesthesiologist must secure the
airway and ensure that intubation does not cause additional damage. The
surgeon evaluates the injury and repairs the severed tissues in order to restore
swallowing, phonation, and respiration. During and following surgical therapy,
the psychiatrist provides proper care and supervision.4
Referensi
1. Shaker K, Winters R, Jones EB. Laryngeal Injury. [Updated 2022 Jul 1]. In: StatPearls.
Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK556150/
2. Mercer, S. J., Jones, C. P., Bridge, M., Clitheroe, E., Morton, B., & Groom, P. (2016).
Systematic review of the anaesthetic management of non-iatrogenic acute adult airway
trauma. British Journal of Anaesthesia, 117, p49–p59
3. Balavenkatasubhramanian J, Mistry T, Gurumoorthi P, Shankar BR. (2020).
Perioperative care in a patient with acute psychosis: Challenges and management. Bali
Journal of Anesthesiology, 4(3), p122-124
4. Hungund S, Hirolli DA, Shaikh SI. Role of anesthesiologist in managing a rare case of
homicidal cut-throat injury. Anesth Essays Res. 2016 Jan-Apr;10(1):114-7
5. Attri JP, Bala N, Chatrath V. Psychiatric patient and anaesthesia. Indian J Anaesth. 2012
Jan;56(1):8-13.
6. Rai S, Anjum F. Laryngeal Fracture. [Updated 2022 Aug 22]. In: StatPearls. Treasure
Island (FL): StatPearls Publishing; 2022 Jan. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK562276/
1