| Abstract|| |
Arrow injuries are rare not only in developed but developing nations as well. Generally used in the sport of archery, arrows are also used as a means of combat in insurgency-ridden regions of India. We report a case of penetrating thorax injury with an arrow lodged close to pericardium in an Oriya woman, referred 15 h after the injury. After a successful surgical intervention with meticulous coordination between the anesthesiologist and surgeon, the patient was discharged after 7 days without complication.
Keywords: Anesthesiologist, arrow injuries, double-lumen tube, penetrating thorax injury, semi-left lateral position
|How to cite this article:|
Kabi S, Sahu AK, Mohapatra BP, Nayak KB. Anesthetic management of thoracic trauma by an arrow. J Emerg Trauma Shock 2021;14:184-6
| Introduction|| |
Injury and trauma, often used in interchangeable fashion, represent a major health problem globally. Daily, around the world, about 16,000 people are killed due to various injuries. It is startling to note that developing countries like India share about 90% of the global burden of injury mortality. Moreover, injury is the third cause of mortality and the main cause of death in the 1–40-year-old age group.
Although penetrating arrow injuries are classified as slow velocity injuries, these may be life threatening, particularly if vital organs (lungs/heart) are affected.
Anesthetic management of these patients is complicated because of the urgency of the surgical intervention, hemodynamic instability, and less-than-ideal posturing of the patient for induction of anesthesia., Many of these surgeries are done out of routine working hours when the availability of resources and personnel may be limited. Furthermore, such patients require a multidisciplinary approach involving surgery, anesthesiology, critical care, emergency medicine, orthopedics, plastic surgery, cardiovascular surgery, and blood banking. Anesthesiologists have an integral role to play in these teams.,
Here, we report a case of a woman with penetrating arrow injury to the dorsal aspect of the thorax. The anesthetic challenges along with the management are discussed.
| Case Report|| |
A 35-year-old female patient was brought to emergency with penetrating arrow injury in the dorsal aspect of the thorax and on the right third intercostal space (ICS), inflicted about 15 h ago [Figure 1]. There was an altercation that resulted in her being shot by a bow and arrow.
The patient was conscious and oriented, but irritable. Her heart rate was regular (100/min) and blood pressure (BP) was 90/60 mmHg. Oxygen saturation (SpO2) was recorded 95% with room air. She was dyspneic with a respiratory rate (RR) of 33/min. There was no history of any comorbidities. Hemothorax was detected on a computed tomography scan. A chest X-ray confirmed the position of the arrow tip penetrating the middle lobe of the right lung and impinging over the pericardium [Figure 1].
There was decreased chest expansion to the right side. Tenderness along with decreased vocal fremitus and decreased vocal resonance were detected. There was dullness and decreased air entry over the right hemithorax. Heart sounds S1 and S2 were normal with no murmur. Glasgow Coma Scale was 15/15.
On airway examination, mouth opening was detected to be of three fingers breadth, and Mallampati Grade was II. The thyromental distance was within normal limits. The temporomandibular joint was normal. There were no loose teeth or removable dentures.
Before transferring to the operation theater (OT), a chest tube was inserted in the 5th, right ICS. In OT, IV access was established by two 16G IV cannulas. Routine monitors of electrocardiography, noninvasive BP (NIBP), and pulse oximetry (SpO2) were connected. A decision to intubate the patient in the semi-left lateral position was taken as the arrow had lodged in the right lung.
The patient was premedicated with injection glycopyrrolate 0.2 mg, injection midazolam 1.5 mg, injection nalbuphine 10 mg, injection pantoprazole 40 mg, and injection ondansetron 4 mg and preoxygenated at 6 L/min for 3 min. Induction of general anesthesia was achieved with injection etomidate 16 mg and injection scholine 75 mg.
The patient was intubated with a 35 fr of the double-lumen tube (DLT) on the left side in a semi-left lateral position. The position was confirmed by end-tidal CO2, auscultation, and fibroscope. It was subsequently fixed at a 28 cm mark at the left angle of the mouth.
Air and oxygen were maintained at a rate of 50:50. Isoflurane was given intermittently at the rate of 1 Mac. injection vecuronium 5 mg IV was given at loading dose, followed by a maintenance dose of 1 mg. A 7 fr triple-lumen CVC and the right radial arterial line were given. Two-lung ventilation was conducted till the opening of the hemithorax. A recruitment maneuver was given by applying a pressure of 40 cm water at the end of inspiration for 15 s. Then, the tracheal lumen was claimed. The right lung was allowed to collapse. One lung ventilation was continued with a tidal volume of 270 ml, RR – 14/min, and positive end-expiratory pressure – 7 cm water.
Surgery was done by thoracotomy. Arrow was retrieved en bloc and the right lung was repaired [Figure 2].
Extubation was uneventful. Spontaneous respiration was observed. Postoperative care included multimodal analgesia with injection paracetamol 1 g TDS, injection tramadol 100 mg BD, erector spine block, and thoracic epidural at the T8 level. Furthermore, nebulization, antibiotics, respiratory, physiotherapy, and incentive spirometry were used.
The patient was discharged after 7 days.
| Discussion|| |
In thoracic penetrative injury cases, initial resuscitation should follow ACLS protocol along with placement of chest drain. If presented with cardiovascular injury and hemodynamic derangements, volume resuscitation with blood must start immediately and surgery should be done immediately. Central nervous system and pupil examination must be done to exclude neurotoxins.
Moreover, as was seen in our case radiographically, there is a major possibility of cardiac damage or blood vessel injury. This leads to severe bleeding. Injury to the lungs may present as bronchopleural fistula, lobar atelectasis, injury to the hilar structure, or any major bronchus injury. Some other mediastinal structures or nerves can also be damaged.
The challenge we faced in this particular case was the proper positioning of the patient for intubation. Airway management, in the presence of a protruding foreign body, is difficult because it often precludes the ideal intubation position. Since the radiograph confirmed the tip of the arrow to be in close proximity of pericardium, even a slight error during intubation could be fatal. Hence, it was decided to place the patient in a semi-left lateral position. This was achieved by placing a pillow below the right shoulder and hip. It was critical since even slight displacement of the tip of the arrow may injure the pericardium or the cardiac chamber leading to catastrophe.
DLT is helpful in such scenarios as they protect the unaffected lung, allow one-lung ventilation, provide an adequate surgical view, and allow ventilation in the unaffected lung.
Postoperatively, the patient should be assessed for lung expansion and repeated chest radiographs are recommended to detect residual atelectasis.
| Conclusion|| |
Anesthesia for a hemodynamically unstable patient with penetrative thoracic surgery, challenging airway management, and imminent emergent surgery requires vigilant monitoring, diligent teamwork, and judicious management to obtain a successful outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta A, Gupta E. Challenges in organizing trauma care systems in India. Indian J Community Med 2009;34:75-6.
] [Full text]
Ogunleye AO, Adeleye AO, Ayodele KJ, Usman MO, Shokunbi MT. Arrow injury to the skull base. West Afr J Med 2004;23:94-6.
Kaur K, Singhal SK, Bhardwaj M, Kumar P. Penetrating abdomino-thoracic injury with an iron rod: An anaesthetic challenge. Indian J Anaesth 2014;58:742-5.
] [Full text]
Tantry TP, Kadam D, Shetty P, Adappa KK, Muralishankar B, Shenoy SP. Penetrating abdominal injury in a polytrauma patient: Anaesthetic challenges faced. J Anaesthesiol Clin Pharmacol 2011;27:272-4.
] [Full text]
Gupta S, Rani R, Nayar R, Sridhar S, et al. Anesthetic management of a patient with penetrating thoracoabdominal trauma. Karnataka Anaesth J 2015;1:149-52..
Aboseif Eman MK. Role of anesthesiologists in the management of trauma patients: Updates. Ain Shams J Anesthesiol2016, 9:153-8.
Mullan FJ, O'Kane HO, Dasmahapatra HK, Fisher RB, Gibbons JR. Mediastinal transfixion with a crossbow bolt. Br J Surg 1991;78:972-3.
Campos J. Which device should be considered best for lung isolation: Double lumen endobronchial tube versus bronchial blockers. Curr Opin Anaesthesiol 2007;20:27-31.
Department of Anesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]