Emergency Management of Cut Throat Injury: A Report of 2 Cases

Introduction

Cut throat injury (CTI) is a type of penetrating neck injury that accounts for approximately 5% of all trauma cases [1]. It is an otorhinolaryngology head and neck surgery emergency and is mostly caused by accidents, self-injury, or attempted homicide [2]. Wounds may involve important organs or parts of the neck, such as the large blood vessels, trachea, esophagus, pharyngeal cavity, nerves, and spinal cord. Patients often have hard signs such as shock, pulsatile bleeding or expanding hematoma, airway compromise, wound bubbling, subcutaneous emphysema, stridor, hoarseness, difficulty or pain when swallowing secretions, and neurological deficits [3]. If doctors lack experience in treatment or do not deal with it properly, CTI can be life-threatening. This paper reports 2 cases of CTI, one of which was attempted homicide and the other was attempted suicide. The purpose of this report is to summarize and review the characteristics, principles, and methods of treatment and precautions during treatment of CTI.

Case Reports

PATIENT 1:

A 69-year-old woman was admitted to our hospital because of bleeding 30 minutes after someone cut her throat. At that time, she was pale, had clammy limbs, was unable to speak, and had occasional paroxysmal cough without hemoptysis or hematemesis. She was unconscious and could not cooperate during the physical examination. Vital signs were temperature, 36.7°C; blood pressure, 115/67 mmHg; respiration, 20 beats/min; and heart rate, 168 beats/min. The neck was bandaged and a large amount of blood was lost. After consultation with doctors in our department, the patient’s condition was evaluated, and a decision was made to perform emergency neck exploration surgery under general anesthesia. During the operation, the patient had dyspnea at 1 point. After removing the neck bandage gauze, 2 wounds were found in front of the patient’s neck, one deep and the other shallow. The longest wound was approximately 10 cm, and the larynx and trachea were cut, which contained a small blood clot. After cleaning, a cuffed endotracheal tube was urgently inserted (Figure 1A, 1B). General anesthesia was administered, and the wound was carefully examined. The thyroid cartilage plate had 2 horizontal transverse incisions of approximately 1 cm in length, the cricoid cartilage was completely disconnected from the first trachea, and the posterior wall of the trachea was lacerated and perforated with the esophagus. No obvious injury to the great vessels or nerves was observed on either side of the neck. With continued exploration of the wound after a low tracheotomy, the sternothyroid and thyrohyoid muscles were found to be ruptured, part of the cricoid cartilage was defective, and the vocal cords were uninjured (Figure 1C). After sufficient hemostasis, laryngotracheal anastomosis and esophageal repair were performed, the esophagus, ruptured trachea, thyroid cartilage plate, and muscle were sutured, and drainage and gastric tubes were placed. The tracheostomy metal cannula was replaced 3 days after the operation. She had no acute stress disorder (ASD) after receiving psychiatric nursing once a week. One month after the surgery, she had no hoarseness and was breathing well. Videostroboscopy showed that the laryngeal cavity had healed well (Figure 1D), and the tracheostomy metal cannula was removed.

PATIENT 2:

A 16-year-old boy was admitted to our hospital because of bleeding 2 hours after he cut his throat in a suicide attempt. He was in poor spirits and could not answer questions or cooperate with the examination. His family told us that he had recently been in a poor mental state, with frequent glazed expressions, and that his mother had a history of schizophrenia. Vital signs were: temperature, 36.6°C; blood pressure, 110/70 mmHg; respiration, 20 beats/min; heart rate, 110 beats/min. A 15-cm-long open wound was found in the middle of the neck, with exposed larynx and trachea, and transverse rupture of the thyroid cartilage (Figure 2A, 2B). He was in stable condition, without hard signs. An enhanced CT scan of the neck was performed urgently, which showed partial tissue defects in the anterior neck and gas accumulation in the surrounding tissue (Figure 2C). After consultation with doctors in our department, his condition was evaluated, and a decision was made to perform emergency neck exploration surgery under general anesthesia. After low tracheotomy, the patient had 3 open wounds in front of and on the left side of his neck. The longest wound, approximately 15 cm, penetrated the laryngeal cavity, with partial rupture of the cervical strap muscles, transverse rupture of the thyroid cartilage plate, and rupture of the left external jugular vein. During surgery, the external jugular vein was ligated, the laryngeal mucosa was sutured with 6-0 absorbable suture, and the ruptured thyroid cartilage plate was sutured with 3 needles with 0 absorbable sutures (Figure 2D), the neck muscles and skin were sutured layer by layer, and 2 drainage skin grafts and gastric tube were placed. The patient was treated for infection prevention after surgery, and after consultation with a psychiatrist, he was treated with olanzapine (2.5 g) orally nightly. After the wound showed no obvious signs of infection, he was transferred to a psychiatric hospital for specialized treatment. One month later, he was discharged and recovered well.

Discussion

Penetrating neck injury is a relatively uncommon trauma with a potential for significant morbidity and mortality. The causes of death are mostly hypovolemic shock, respiratory obstruction, or severe infection due to large-vessel injury. Timely and active surgical intervention is key to the successful treatment of penetrating neck injuries [2,4].

Anatomically, the neck can be divided into 3 major zones for surgery [5]: Zone 1 is below the cricoid cartilages to the thoracic inlet, zone 2 is from the cricoid cartilages to the angle of the mandible, and zone 3 is above the angle of the mandible. Injuries at zone I may result in damage to subclavian arteries, veins, and lungs, usually pneumothorax or hemothorax; injuries at zone 2 often involves the carotid artery, internal jugular vein, esophagus, and trachea; and the main injuries at zone 3 are at the internal carotid artery. Some scholars believe that the neck should be evaluated as a single unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries [3,6]. Radiological examination, including chest X-ray, CT scan, neck ultrasonography, and contrast imaging, can further aid in diagnosis but are sometimes omitted due to time constraints [2]. In fact, the primary survey of trauma patient uses a mnemonic for the sequential management priorities of airway, breathing, circulation, and disability (ABCD). Airway management remains the crucial first step in the management of trauma patients. CT scans are relatively contraindicated in hemodynamically unstable patients [7]. Therefore, patients whose condition is unstable should undergo immediate surgical exploration and those whose condition is stable without hard signs should undergo enhanced neck CT to assess the injury [3]. Both of our patients had incisions in zone 2, and the situation of Patient 1 was so urgent that exploratory surgery was chosen directly, and Patient 2 was stable, so exploratory surgery was performed after enhanced neck CT.

Challenges in the management of CTI in the emergency department range from airway management to controlling ongoing blood loss and subsequent hemorrhagic shock [8]. In cases of airway obstruction, aspiration due to severe bleeding, or in patients with GCS <8, active airway management is performed, which includes placement of a cervical collar, tracheostomy, cricothyroidotomy, intubation through the injured site, and oxygen inhalation [7]. Patients with CTI should not undergo tracheal intubation blindly when there is uncertainty about bleeding or tracheal or cartilage damage, which can easily cause secondary trauma or massive bleeding [4]. In our 2 patients, the emergency physician only used gauze to compress the neck, and did not insert a tracheal cannula through the open wound for the first time to maintain airway patency. Patient 1 had dyspnea at 1 point, and the respiratory obstruction was relieved after a cuffed endotracheal tube was urgently inserted through the open wound in the larynx. Fortunately, Patient 2 had a stable neck wound that did not bleed much, and he did not have blood clots blocking the airway.

CTI often causes serious cervical blood vessel injury. When the airway is patent, the first step is not to remove blood clots or tamponade from the wound, but to control bleeding and replenish blood volume. If the external carotid artery, external jugular vein, or internal jugular vein are injured, ligation should be performed. When a common or internal carotid artery injury is identified during neck exploration, the consensus from the literature suggests that repair of the artery has superior patient outcomes than artery ligation, and 50% of the diameter of the vessel should be retained as patently as possible, and the inner surface should be smooth to prevent postoperative thrombosis [9,10]. Patient 1 had no major vascular injuries, and Patient 2 had injury to the external jugular vein, which was ligated.

CTI often causes throat, trachea, and esophagus injury, so meticulous and early repair of the laryngeal mucosa, pharynx, and esophagus should be performed in layer closure to prevent serious complications such as laryngotracheal stenosis, dysphonia, wound dehiscence, granulation tissue, and fistula formation [11]. The repair effect of open pharyngeal and laryngeal injuries is good within 24 hours after injury, and the incidence of wound infection and pharyngeal fistula is low [12]. Gastric tubes should be placed to reduce the risk of wound contamination and pharyngeal and esophageal fistulas, and a high-nutrient liquid diet should be commenced. While repairing a wound, it is necessary to explore the surrounding nerves, such as the vagus, recurrent laryngeal, and accessory nerves. Patient 1 had severe larynx and trachea injury to the esophagus, whereas Patient 2 had a ruptured larynx without injury to the vocal cord. After timely repair surgery and gastric tube diet, the wounds of both patients healed well.

Patients with CTI often suffer from mental illness or psychological trauma caused by attempted homicide, so the patient’s condition should be closely monitored during recovery. Suicidal patients should be prevented from secondary suicide. Patients with trauma are at high risk of developing serious mental health disorders, ASD, and post-traumatic stress disorder (PTSD) [13]. Therefore, to prevent these problems, timely psychological intervention should be carried out for patients with psychological trauma caused by attempted homicide. Both patients in this report received professional psychiatric treatment after surgery.

Conclusions

Form the successful treatment of 2 patients with CTI, we learned several lessons. Airway management is the critical first step in management of patients with CTI, and the tracheal cannula should be inserted through the opening in the injured larynx for the first time to maintain airway patency. Patients whose condition is unstable should undergo immediate surgical exploration, and those whose condition is stable without hard signs should undergo enhanced neck CT to assess the injury. Prompt psychiatric care is also critical.