INTRODUCTION:
Cut throat injury is referred
to a laceration or a stab by a sharp object, which may be superficial or penetrating in nature. Cut throat injury can be
classified into self-inflicted or non-self-inflicted which results from
accident, homicides or suicide (reference). It may present as a single injury
or along with multiple injuries1,2,3. This case report addresses the
multidisciplinary involvement in management of cut throat injury sustained by a
young man following a homicide attempt
CASE
PRESENTATION
The patient
is I. U., A 28yr old male, from Benue State of the North Central region of
Nigeria. He has Secondary level of education,(is a commercial tricycle driver
by profession and also a mechanic).Patient was rushed to emergency room of the
Rivers State University Teaching Hospital following a history of slit throat. A
brief history taken at the emergency room revealed patient was found on his
bedroom floor with multiple cuts to the throat and body with a sharp knife.
Injuries sustained were double horizontal linear slits to the throat approximately
4 cm apart. There were noticeable lacerations to the abdomen and also slits at
the wrist bilaterally volar aspect of the fore arm. He was dyspneic with bloody
frothing at the site of the cut throat and at the nose during respiration.
Respiratory rate was noted to be 46cycles per minute, pulse oximeter gave a
value of 89%. The pulse rate was 104bpm with a blood pressure of 90/56mmHg.
Initial resuscitation was commenced in accordance with the ATLS protocol: The
airway was cleared and debris suctioned off. Oxygen via nasal prongs was
provided while the wound was bandaged and arrangements made for a definitive
airway via an emergency tracheostomy. A preliminary exploration of injuries was
made and active bleeding points arrested .Two large bore cannula were inserted
and patient resuscitated with initial 2 liters of isotonic ringers lactate .A
urinary catheter was also left in-situ to monitor patients tissue perfusion
.SpO2 monitoring was continued with O2 saturation
maintained at above 92% and 2 units of
blood provided prior to surgery .Reviews were also obtained from the Surgical
team on emergency call duty and also the anesthetics. Consent was obtained from
the relatives (father) and patient post haste to the operation room for an
emergency tracheostomy, neck exploration and repair.
Patient
was rushed into the operating room and an endotracheal tube inserted through
the wound to the trachea directly and the cuff applied. The airway was
suctioned and hemostasis around the exposed neck secured via pressure with sterile
gauze and ligature with absorbable sutures. An emergency tracheostomy was done
below the cut throat injury and a cuffed tracheostomy tube was inserted at the
3rd to 4th tracheal rings. The T-tube cuff was inflated
to protect the tracheobronchial tree and exploration of the neck commenced
under general anesthesia. The slits were irrigated using normal saline
approximately 2 liters and careful exploration of the wounds done. Findings
were; 2 horizontal anterior neck
incisions about 10cm and 8cm
in length exposing the hypopharynx and larynx , laceration of the
thyroid cartilage ,transection of the anterior aspect of the trachea with
approximately 2cm of the posterior
segment still intact and lacerations on both wrists with superficial abdominal.
Examination of the larynx revealed adduction and abduction of the vocal cords with blood clots
on the surface and airway.
Exploration
of the injury was done with repair of the larynx and trachea done in layers
using vicryl suture and careful tissue alignment to maintain adequate airway
.The muscular layer was carefully opposed and skin closure done via interrupted
nylon sutures. The lacerations on the wrist was repaired and wound dressing
done on the superficial cuts on the abdomen
Post operatively,
vitals signs were closely monitored and management of cuffed tracheostomy tube
care done. He was on nil per oral and administered anti – tetanus toxoid, antibiotics,
analgesics, intravenous fluids and intravenous steroids
By the 1st
post-operative day, vital signs of the patient had stabilized with a pulse rate
of 96 beats per minute and blood pressure of 120 / 80mmHg
By the 3rd
post-operative day, patient was noted to have started phonating despite the
tracheostomy tube and was completely ambulatory. However, neck x-ray done showed
mild soft tissue emphysema which was not palpable during cervical examination.
He was able to tolerate fluid diet without aspiration, which was later advanced
to semisolids and weaned off tracheostomy by the 5th postoperative day due to
decannulation of the tube. By the 10th day post-operative period, patient had markedly
improved and was able to phonate clearly and communicate with caregivers and
relatives. Wound healing was adequate with planned skin suture removal. Every
other system was adequate and patients recovery was satisfactory. A repeat X-ray of the neck of
the neck done 2 weeks post procedure showed a well aligned airway as seen in
Fig 3.
Patient
was reviewed 8 weeks post operatively and the outcome was satisfactory
following examination and direct laryngoscopy. He was referred to see the Neuropsychiatrist
for review and further management due to his trauma and history of drug use.
Case
review by the Neuropsychiatry team:
During the patients
review by the neuropsychiatrist, He
was said to have been in his usual state of health until about 2 months ago
when he was ambushed by assailants who had broken into his apartment prior to
his return that evening. He had returned to his room which was in a blackout
and attempted to lie down on his bed to retire for the day when the assailants,
3 in number, pounced on him and immediately slit his throat with a sharp
object. On further attempts to fight them off, they slit his wrist. This was
the last he remembered. He woke up the next morning, crawled out of his
apartment and called for help before passing out again.
Further
interview revealed that he had been a user of cannabis of which he started
using this substance 9 years ago at the age of 18years old after he was
introduced to it by his elder brother. He started out by smoking a drag which
made him feel good and able to concentrate properly. This feeling made him
return for more as he increased use to about a wrap within the space of one
month in order to attain the same effect. When substance is not in use, he
feels as if time slows down and he cannot concentrate. He constantly craves substance
and abandons other sources of pleasure to seek it. He funds his substance abuse
from monies he makes from his hand work. He has not had conflicts with family,
superiors or occupational hazards following use of substance. He currently
makes use of 2 to 3 wraps daily. He claims he last used substance 2 days prior
to the incident of his cut throat. He admitted to the use of other psychoactive
substances such as tramadol and codeine. However, last use was 6 years
ago.
He
also gave a history of hearing of strange voices unheard by others in clear
consciousness of 6 years duration. Voices are multiple, familiar recognized as
his mother and childhood friends discussing his actions. This occurs infrequently
about 3 to 4 times weekly with periods of quiescence lasting a month in between
episodes. He says voices make him feel nervous but he has never acted on them. He
last heard the voices about 3 weeks prior to incident.
No
history of seeing of strange objects in clear consciousness or other perceptual
abnormalities in other modalities. There's a positive history thought
broadcast and thought insertion. He feels that his actions are occasionally controlled
by forces external to him. However, he does not believe he is discussed or
referred to in other media.
No
history of low mood, loss of interest in previously employable activities, low
energy, worthlessness or guilty feelings. He denied death wishes, suicidal
ideations or attempts.
No
history of decreased need for sleep, increased feelings of energy, talkativeness,
elated or elevated mood. No history of excessive spending of monies except in
purchase of cannabis. No history of undue fearfulness, tremors, dryness of
the throat, excessive sweating or other features of autonomic overdrive.
This
interview was done over the telephone as patient was unable to go for a clinic
consultation due to financial reasons. A
further review was required as certain key details could not be obtained over
the phone interview. Based on the current review an impression of mental and
behavioral disorder due to cannabis dependence, schizophrenia like (ICD 10
Diagnostic criteria) was made. The following psychiatric problems were
elicited:
1.
Prolonged use and dependence on a psychoactive substance (cannabis).
2.
Psychotic Symptoms - 3rd person auditory hallucinations (discussing), thought
insertion and broadcast, made volition (passivity phenomenon).
Patient
was encouraged to attend the clinic for further management, of which he is yet
to do.
DISCUSSION
This paper
reviews the management of a young man with multiple cuts to the throat, wrists
and abdomen. Cut throat injuries due to homicides and suicides usually require
rapid and interdisciplinary treatment7 . The anesthetist and
psychiatrists working in conjunction with the Otolaryngologist should manage
these patients 7. Cut throat injury can be as a result of suicide,
homicide or accidents. Most times self-inflicted cut throat injury are as a
result of suicide8. Suicide is a known cause of death among
individuals with psychiatric illnesses 9, familial troubles and
poverty10. However there are some instances where individuals who are
intoxicated by substances and not in their right frame of mind resulting in self-harm
which may involve cutting their throat with a sharp object11There is
limited literature on multidisciplinary approach done on cut throat injury with
patients with substance abuse, this is probably due to most cases being under
reported or captured under suicide without the surrounding elements such as
drugs /substance abuse as a predisposing factor to the self-inflicted cut
throat injury8 . Cut throat injury may be with associated multiple
injuries as seen in this case or present as a single injury.
The neck
is anatomically divided into 3 zones. The
zones 1 and 3 have bony protection unlike that of zone 2 which is
located between the cricoid and angle of the mandible, this area is devoid of
protection by bone unlike the other zones and thus pose a higher risk of injury
to structures of the neck2,3.
Cut throat
injury occurs at zone 2 , of which injuries to the neck at this zone are
potentially life threatening due to the vital structures present. There is a
possibility of damage of vital structures which may result in complications
such as massive hemorrhage, asphyxia
from aspirated blood, shock, major vessel damage can result in exsanguination , air embolism and death.
Prevention
of these complications depend on immediate resuscitation by securing the
airway via tracheostomy or intubation,
prompt control of hemorrhage and blood replacement if necessary, prompt
intervention or operative treatment when indicated7. There is a
place for tracheostomy in the management of cut throat injury which was done in
this case and its worth is highlighted in other studies4,5
The extent
of surgical repair depends on the extent of injury. The injuries may be superficial or deep , which
determines the extent of surgical intervention
during management .In this case with multiple neck lacerations, a tracheostomy
was inserted below the injury to protect the tracheobronchial tree and relieve
upper airway obstruction which would have occurred due to edema following the
trauma and laryngeal repair. This is similar to other similar cases of
management in which establishing an
airway either via endotracheal intubation or tracheostomy is done prior to
surgical repair of the transected tissues5,6.The exploration and
repair of the trachea, larynx and soft tissues in this index case was done in
layers to give a better out come8.
Patients
of cut throat injury due to homicide need psychological support to overcome the
trauma which may linger long after the wounds heal6. In this case,
the review yielded more insight to the possibility of substance abuse and
generated further assumptions and questions. The patient has been on prolonged
use and dependence on cannabis which is a psychoactive substance.
Cannabis has been associated with development of
schizophrenia. A substantial body of observational evidence supports the
hypothesis that cannabinoids play a role in the development of schizophrenia.
Prospective observational studies, with decades of follow-up and accounting for
a large number of potential confounding factors (such as demographic, family
history, personal history, socioeconomic or other environmental markers) have
consistently demonstrated that exposure to cannabis is associated with an
increased risk of schizophrenia or related disorders. These findings have been
reinforced by basic research experiments that point to cannabis altering
various neurotransmission pathways linked to pathogenesis of psychotic
disorders and by interfering with neurodevelopment in adolescents12.
A
systematic review on the relationship of psychosis and self-harm revealed that
the experience of psychotic-like symptoms is significantly associated with a
two-and-a-half to three-fold increased risk of suicidal behavior and, arguably,
should be considered a risk marker indicative of vulnerability to both
self-harming behavior and to suicide13.
There
is a possibility that:
1.
This patient was physically attacked by assailants
2.
He might have acted under the influence of the substance following a distortion
of his ego boundary
3.
He might have acted under the influence of the psychotic phenomena such as
obeying the voices heard in the hallucinatory experiences, the thought
disorders or the influence of the made volition.
The review was
necessary due to the psychological trauma he encountered from the incident and
in this case substance abuse and drug addiction. The Patients’ reluctance to
follow up on medical review and management by the neuropsychiatrist despite his
reason indicates he is unaware of the importance of this care, probably due to
the absence of physical consequence to him at this time.
CONCLUSION
Cut throat injury is
an emergency which requires a multidisciplinary approach for adequate management.
This was appreciated in this case as all hands were on deck in management of this
patient by the trauma surgeons in the accident and emergency room, the
anesthetists, otorhinoloarngologist and neurophyschatrtis. Their impact cannot
be over emphasized as every aspect was critical in this patients care from
ensuring adequate airway, securing hemostasis,
repair of severed tissues with the aim of restoring swallowing, phonation and
breathing as well as psychological
review of the patient who survived a
homicide attempt and has a drug addiction prior to the cut throat incident. The
post-operative care for anxiety and drug addiction is very important as it is
an invisible trauma. Awareness is
paramount on the importance of a psychological review by the neuropsychiatrist of patients who have under gone traumatic
events to ensure a general wellbeing long after the physical wounds have
healed.
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