INTRODUCTION

Penetrating neck injuries are rare but challenging as it can be associated with airway injuries and potentially be life threatening (Verdonck et al. 2016). The neck is divided into three zones each containing vital structures. These zones are not easily accessible by physical examination or surgical exploration in the event of injuries to any of these vital organs.The main initial priority upon presentation in the emergency department is to establish a secure airway (Wehbe & Hoballah 2017). The common approach to secure airway include endotracheal intubation, surgical cricothyroidotomy or tracheotomy (Bell et al. 2007). We present an unusual case of penetrating neck injury that securing the airway with these methods were not feasible.

CASE REPORT

A 74-year-old man with background history of diabetes, hypertension, and coronary artery disease was brought to Emergency Department (ED) by the pre-hospital team with alleged suicidal attempt. He tried to slash his neck with a knife and was found by his brother lying on the bathroom floor.

On arrival at ED, he presented with haemoptysis, dysphonia and tracheahaematemesis. He was conscious but restless. There was no stridor. High flow oxygen 15 L/min by non-rebreathing mask was started by the paramedic team enroute to the hospital. There was a wide open laceration wound over the anterior neck measuring about 10 cm x 2 cm at the level of cricothyroid cartilage with surgical emphysema felt at the margin of the wound. However, there was no active bleeding orabnormal breath sounds heard from the open laceration wound. Lung auscultation revealed equal air entry with minimal bibasalcrepitation. There were no other injuries elsewhere. Peripheries were warm, with good pulse volume Vital signs shows pulse of 101per minute, blood pressure 100/70mmHg and oxygen saturation of 100 % under oxygen high flow mask 15L/min.

After the assessment of the airway, the decision was made with the anaesthesia team to intubate the patient before sending the patient to operation theatre for repair of laceration wound. Two large bore intravenous cannula were inserted and blood samples were taken for group cross match and full blood count. Patient was premedicated with Fentanyl 50 mcg, Midazolam 5 mg and Succinylcoline 50 mg prior to glidescope assisted intubation. An endotracheal tube size 7 mm was inserted via the oral cavity but came out from the open laceration wound and caused an obvious defect to the airway. The procedure was immediately aborted as patient’s oxygen saturation deteriorated rapidly. In the face of airway emergency, an endotracheal tube size 5mm was inserted through the tracheal defect (Figure 1).

The patient was sent to operation theatre after securing the airway for wound exploration, repair of laryngeal wound and tracheostomy.

DISCUSSION

Penetrating neck injury accountsto 5-10% of all traumatic injuries (Aich et al. 2014). Injuries may involve structures like the trachea, oesophagus, great vessels and even the thyroid or parathyroid glands. The presence of dysphonia, hoarseness and blood productive cough should alert the attending physician of a possible airway disruption. Hard signs of airway disruptions such as subcutaneous emphysema, stridor and presence of bubbling around the wound should be actively sought and appropriate emergency actions for airway control initiated.

Between 50-80% of penetrating neck injuries occurs in zone II of the neck which extends from the cricoid cartilage to the angle of the mandible (Nason et al. 2001). Immediate supplementation of oxygen should be initiated for all the patients with possible airway injury. In the presence of this patient’s signs and symptoms of dysphonia, blood productive cough and subcutaneous emphysema, an immediate attempt to establish a secure airway was necessary. Endotracheal airway intubation should be attempted in all patients with neck injury except in severe maxillofacial trauma (Davari & Malekhosseini 2005). This can be performed either by direct or video laryngoscopy depending on the equipment available. Fiberoptic bronchoscopy is extremely useful as the vocal cords can be identified and the lumen of the trachea can be visualized, but may not be readily available in the emergency department.

The physician performing the endotracheal intubation should be prepared that if the airway is partially obstructed secondary to a tear or injury, it can be converted to a complete transection or obstruction by this attempt. The transected distal-end of the trachea could be identified and an appropriate size tube inserted to temporarily maintain a patent temporary airway before surgical repair (Bhattacharya et al. 2009). If this is unsuccessful, a surgical airway kit and expertise to perform a tracheostomy should be available and could be difficult due to the distorted injury and anatomy.

Rapid sequence intubation using sedatives, inductive agents and paralytic drugs may remove airway reflexes and any effort for the patient to control the airway and breathing. In the situation where the attempt of intubation fails and bag valve mask ventilation cannot maintain adequate oxygen saturation, immediate decision to secure the airway surgically is of the upmost importance. A senior and experienced physician should be available or awake intubation should be attempted without the use of induction or paralytic agents.

CONCLUSION

Anticipation of a failed airway should always be at the back of the mind of any emergency physicians that encounter cases of open neck injury. An initial assessment that suggest the most likelihood of organs that are involved can guide in the choice of appropriate management. Options include conventional orotracheal intubation, direct intubation through the laceration wound or tracheostomy.