Successful management of a life-threatening penetrating neck injury following a road traffic accident - A case report

INTRODUCTION

Penetrating neck injury is defined as a breach of the platysma muscle following trauma^[1], which leads to significant morbidity and mortality. Penetrating neck injury represents 5-10% of all trauma cases.^[2] The rising incidence of road traffic accidents globally has also led to an increased incidence of penetrating neck injury.^[3] In general, work-related motor vehicle accidents contribute to at least one-third of all work-related accidents and are a considerable cause of economic loss to the individual and their families.

CASE REPORT

A 20 year old male patient weighing 52kg was brought to the emergency department of our hospital with a penetrating lacerated injury of the neck following a road traffic incident involving a barbed wire. At the time of presentation in the emergency, the patient was conscious but agitated and unable to vocalise as the trachea was split into two pieces transversely. A visible lacerated wound of 7-8 cm, around 4 cm below the cricoid cartilage (Zone I), and visible bubbling of air from the wound was present. His vitals included a blood pressure of 100/70 mmHg in the supine position, a pulse rate of 130 beats/minute and an oxygen saturation of 90 % on room air. No signs of active bleeding from the lacerated wound were present, and assessment of the thorax, abdomen and pelvis was found to be normal.

Resuscitation was started as per Advanced Trauma Life Support (ATLS) guidelines^[4], and the patient was shifted to the operating room (OR) in view of impending airway compromise. Intravenous lines were secured using two wide-bore (18G) IV cannulas, and infusion of crystalloids was started. Oxygen was supplemented at 4 L/min using a nasal cannula while the patient was shifted to the OR. On arrival to the OR, 12-lead electrocardiogram (ECG), pulse oximetry (SPO₂) and noninvasive blood pressure (NIBP) monitors were connected and injection (Inj.) ketamine 20 mg along with Inj. glycopyrrolate 0.2 mg by the intravenous route were given to facilitate surgical exploration. On exploration, the distal end of the trachea was at the sternal notch, and the proximal end of the trachea was found hanging with obliterated thyroid and cricoid cartilage with intact posterior wall. To provide a definitive airway, an endotracheal tube (ETT) of 7mm internal diameter (ID) was inserted into the distal end of the trachea with the help of an artery-forceps for pulling the distal trachea from the sternal notch. The cuff was then inflated and the ETT was secured after confirmation of bilateral air entry with the help of sutures to adjoining structures [Figure 1a]. General anaesthesia was then induced with Inj. ketamine 60mg and Inj. fentanyl 100 µg by IV route and maintained on oxygen 2L + nitrous oxide 2L + sevoflurane 2% as per institutional protocol. We preferred ketamine as an induction agent to avoid any hypotensive episode and to maintain a better haemodynamic profile during airway management. During tracheal reconstruction following oesophageal repair, a gum elastic bougie was inserted from the right nostril to the proximal tracheal stump using Magill forceps. Following the posterior tracheal wall correction, the ETT in the distal trachea was gradually withdrawn while the bougie was advanced into the distal tracheal stump. Once the bougie was in the distal trachea, a flexo-metallic ETT of 7mm was railroaded over the bougie into the trachea from the right nostril and surgical reconstruction of the anterior wall of the trachea was initiated after confirmation of bilateral breath sounds and securing the ETT. Primary repair of the trachea was done along with the floor of the mouth [Figure 1b]. Feeding jejunostomy was done for the nutritional requirements of the patient and to allow proper healing time for the oesophagus. After completion of surgery, the patient was shifted to the critical care unit for elective ventilation for 5 days. The patient was discharged in stable condition after 15 days of intensive care, and after 6 months of follow-up, the patient appeared in the review clinic with no active complaints.

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Figure 1a:

Securing the airway through the distal end of the trachea in a penetrating neck injury

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Figure 1b:

Endotracheal intubation through the right nostril

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DISCUSSION

Penetrating neck injury is an uncommon presentation in the emergency department but poses a unique challenge to the emergency physician or surgeon. The neck, being a densely packed area without a protective bony shell, with several vital structures (aerodigestive, vascular, neural), carries a high risk of morbidity and mortality.

Penetrating injuries of the neck have traditionally been managed and described on the basis of entry point of the penetrating injury^[5] into the following zones, Zone I: from the clavicles and sternum superiorly to the cricoid cartilage, Zone II: from the cricoid cartilage superiorly to the angle of mandible, and Zone III: from the angle of the mandible superiorly to the base of the skull, but the growing evidence has shown a disconnect between the external injury location and identified internal injuries intraoperatively^[6] highlighting the importance of non-zonal approach in these set of patients. ATLS guidelines can be used to guide the evaluation and assessment of the patient.

Managing the injured airway is critical, and timely management as per the patient’s clinical condition, available resources and the skills of the provider should be the main focus. Any delay or failure in securing the airway increases the risk of death as the airway may worsen over time (dynamic airway). In our case, initial intubation of the distal end of the trachea was performed under direct visualisation, and later the ETT was passed through the right nostril and exchanged over the bougies once the surgical reconstruction of the posterior wall of the trachea was completed under general anaesthesia. We avoided the initial approach by the nasal route to avoid unnecessary delay in airway management, as the distal cut end of the trachea was easily intubated using the ETT under ketamine sedation, and blind navigation of the ETT was limited to prevent any further chance of damage to tissue.^[7]

We immediately planned for surgical intervention, bypassing the radiological imaging, in view of impending airway compromise, visible bubbling of air through the wound site and the risk of developing shock. The decision to take a patient presenting with a penetrating neck injury for surgical intervention, bypassing imaging, is largely dependent on the patient's physiological status and clinical findings on examination.^[8] Presence of ‘hard signs’ (severe haemorrhage, shock, expanding haematoma, airway compromise, emphysema, etc.) following penetrating injury should alert the attending physician, and an emergency surgical consultation and operative exploration should be the choice.^[9]

CONCLUSION

Successful management of penetrating neck injury requires a timely team approach. Haemostatic resuscitation, securing a definitive airway, control of bleeding and early surgical exploration should be the priorities when managing these patients. Individualising the needs of the injured and providing a tailor-made approach as per available resources can have a long and fruitful impact on patient well-being.