JOURNAL CLUB PRESENTATION

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AN UNUSUAL CASE OF PENETRATING TRACHEAL ( CUT THROAT) INJURY DUE TO CHAIN SNATCHING : AN IDEAL AIRWAY MANAGEMENT

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INDIAN JOURNAL OF CRITICAL CARE MEDICINE JULY - SEPTEMBER 2007 VOLUME 11 ISSUE 3

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INTRODUCTION:

Penetrating airway injuries of the neck accounts for 3 cases per year per emergency department

associated with larynx 5 15 % associated with carotid artery injury and digestive tract 1 2 %

As the connective tissue of cricoid is very weak its more prone for injury.

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Case Report:
A 25 year old female patient was taken to emg dept. with alleged history of chain snatching while she was travelling in a two wheeler as a pillion.

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She had the complaints of :

severe bleeding from neck, Severe pain around the neck, difficulty in breathing, difficulty in swallowing and difficulty in phonation.

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General examination:
Patient was conscious, restless, dyspnoeic, tachypnoeic, anemic and in shock. Pulse 167 / min. BP 60 / ? mmHg. SaO2 Not recordable.

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Systemic examination:
CVS Evidence of unstable haemodynamics RS - Vesicular breath sounds heard, bilateral crepitations +, bilateral wheeze +, P / A- Soft, no organomegaly, CNS Pt. was restless, Higher mental functions intact, Cranial nerves normal,
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Bil. Pupils equally reacting to light,

Local examination:

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1. Severe bleeding from the neck, ( bleeding was minimised by applying compression over the wound using saree by the pts husband. ) 2. Cut throat injury with sliced trachea.

Routine blood investigations were taken.

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MANAGEMENT AT THE EMERGENCY ROOM :

Two I. V. Lines were secured in both the

cubital fossa with two wide bore 16 g IV cannulae.

1000 500

IV Fluids :
ml of crystalloids, ml of colloids were given.

Compression pack was placed around the

neck wound.
4 units of blood and
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2 units of fresh frozen plasma ( FFP ) were

Patient was intubated orotracheally and was put on full ventilatory support.

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On laryngoscopy, the entire oropharyngeal area was flooded with blood and was not controlled by oropharyngeal suctioning. ET tube was placed and it was filled with aspirated blood and so removed by endotracheal suctioning. Ryles tube was placed in the oesophagus.

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Patient was shifted to the OT with the support of ambu assisted ventilation for tracheostomy and

wound closure under general anesthesia.

Anesthetic agents used: Ketamine 50mg IV Atracurium 20 mg IV

100% oxygen was given.

5/4/12 Maintenance was done with

Compression pack was removed from the neck.

There was no large vessel bleed, diffuse bleeding from the minor vessels. The cuff of the ET tube was seen protruding out of the partially transected trachea.

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After achieving haemostasis a 7 size cuffed tracheostomy tube was inserted after removing the ET tube. As the anterior 2/3 rd of the trachea was partially transected, a single suture was applied on either side of the tracheostomy tube to reduce the gap so as to prevent aspiration. Thyroid gland was found to be partially injured. No obvious nerve or oesophageal injuries.

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Wound was throughly irrigated with saline and antiseptic solutions. A drain tube was placed in situ and the wound was closed in layers. Post operatively patient was shifted to ICU. After 24 hrs following surgery she was started on liquids through Ryles tube.

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Tracheostomy tube inserted into the partially transected trachea :

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Patient was kept on ventilator for 72 hrs and during this time the radiological and haematological investigations were observed daily. Patient was weaned off from the ventilator after 72 hrs. Ambulation was encouraged after 96 hrs. Tracheostomy was removed on 7th POD.

Patient was started on oral diet from 8th POD. 5/4/12

Initially she had horseness of voice but later she was able to speak normally. Tracheostomy wound healed well. Swallowing and cough reflexes were adequate. Pt. was discharged on the 14th POD and pt. was asked for a regular follow up. During the follow up pt. was asymptomatic.

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14th post operative day shows wound healed well

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DISCUSSION :

1. The cause of injury for our patient?

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2. Why the radiological investigations are not carried out pre-operatively in this patient?

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3. Is the radiograph, the ideal diagnostic procedure?

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4. Why not regional anesthesia?

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5. Problems encountered during general anesthesia?

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6. Post-op care?

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THANK YOU

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