Düşme sonrası hayatı tehdit eden boyun yaralanması: Bir olgu sunumu

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Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:34, Sayı / No:1

INTRODUCTION

Accident-related neck region injuries are un-common (1). The neck region contains several vitally important structures. Large vessels, the trachea and the initial part of the medulla spi-nalis are all under threat in neck injuries. Neck injuries may be cutaneous-subcutaneous and muscular in origin, and may sometimes be as-sociated with large arteries and the respiratory system, while potentially life-threatening pene-trating injuries may be seen affecting structures associated with large vessels and the respira-tory system. Severe problems associated with respiration and circulation may be seen in inju-ries in this region.

This report describes a child patient with innom-inate artery and tracheal injury following pene-trating injury to the neck region after falling onto a glass table while playing at home. The injuries healed without sequelae after early diagnosis and treatment.

CASE REPORT

A 7-year-old girl was brought to the emergency department with a neck injury resulting from falling onto a glass table while playing at home. Examination revealed a 6-cm lesion in cutane-ous and subcutanecutane-ous neck tissue. After first aid, the patient was transferred by ambulance to

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1 Cardiovascular Surgery Clinic, Dr. Siyami Ersek Hospital, Istanbul, Turkiye

2 Department of Forensic Medicine, Faculty of Medicine, Dicle University, Diyarbakir, Turkiye 3 Department of Forensic Medicine, Faculty of Medicine, Uludag University, Bursa, Turkiye

CLINICAL FORENSIC MEDICINE CASE REPORT

ADLI TIP KURUMU MALATYA GRUP BAŞKANLIĞI’NA GELEN TAMAMLANMIŞ INTIHAR OLGULARININ PSIKOLOJIK OTOPSI YÖNTEMI ILE INCELENMESI INVESTIGATION USING PSYCHOLOGICAL AUTOPSY METHOD OF COMPLETED SUICIDE CASES COMING TO THE COUNCIL OF FIRENSIC MEDICINE, MALATYA REGIONAL OFFICE MORG IHTISAS DAIRESI’NDE OTOPSI YAPILAN OLGULARDA VERILEN ÖLÜM SEBEPLERININ SINIFLANDIRILMASI VE STANDARDIZASYONU CLASSIFICATION AND STANDARDIZATION OF CAUSE OF DEATHS IN AUTOPSY CASES OF MORGUE DEPARTMENT BIYOGÜVENLIK IÇIN OTOPSI ÖNCESI ALINAN KANLARIN MIKROBIYOLOJIK TARAMA TESTLERI AÇISINDAN DEĞERLENDIRILMESI EVALUATION OF BLOOD SPECIMENS COLLECTED BEFORE THE AUTOPSY FOR MICROBIOLOGICAL SCREENING TESTS IN TERMS OF BIOSAFETY

ISSN: 1018-5275 (PRINTED) 2149-0570 (onlıne)

34 1/2020

JOURNAL OF FORENSIC MEDICINE JOURNAL OF FORENSIC MEDICINE

ÖZET:

Kaza kaynaklı boyun bölgesi yaralanmalarına nadiren rastlanmak-tadır. Boyun bölgesi hayati öneme sahip çok sayıda anatomik yapıyı içermektedir. Büyük damarlar, trakea ve medulla spinalisin baş-langıç bölümü boyun yaralanmalarında etkilenebilir. Boyun bölgesi yaralanmaları, cilt-cilt altı ve kas kaynaklı olabilirken bazen büyük damar, solunum sistemi ilişkili olup hayatı tehdit edebilen penetran yaralanmalarla karşılaşılabilmektedir. Hızlı tanı ve tedavi mortali-teyi azaltıp sekelsiz iyileşmeyi sağlamaktadır. Dolayısı ile olgular acil tanı ve cerrahi müdahaleyi yapabilen sağlık merkezlerine sü-ratle ulaştırılmalı ve hızlı tanı konularak etkili yönetim yapılmalıdır.

Anahtar Kelimeler: Boyun yaralanması, innominat arter, trakea.

ABSTRACT:

Accident-related neck region injuries are uncommon. The neck re-gion contains several vitally important structures. Large vessels, the trachea and the initial part of the medulla spinalis can be af-fected in neck injuries. These may be cutaneous-subcutaneous and muscular in origin, and may sometimes be associated with large arteries and the respiratory system, while potentially life-threate-ning penetrating injuries may also be encountered. Rapid diagnosis and treatment reduce mortality and permit sequelae-free healing. Cases must therefore reach health centers capable of providing emergency diagnosis and surgical intervention very promptly and effective management must be provided with rapid diagnosis.

Keywords: Neck injury, innominate artery, trachea. J For Med 2020;34(1):58-61 doi: 10.5505/adlitip.2020.51422 available online at: www.adlitipdergisi.com Received: 13.06.2019 Accepted: 19.09.2019

Düşme sonrası hayatı tehdit eden boyun yaralanması: Bir olgu sunumu

Life-threatening neck injury after a fall: A case report

İsmail Başyiğit1_{, Ertuğrul Gök}2_{, Recep Fedakar}3

Corresponding author: Ertuğrul Gök

Department of Forensic Medicine, Faculty of Medicine, Dicle University, Diyarbakir, Turkiye email: ertugrulgk@gmail.com

ORCID:

İsmail Başyiğit: 0000-0003-3238-2288 Ertuğrul Gök: 0000-0003-1573-283X Recep Fedakar: 0000-0002-2029-9674

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university hospital emergency department. In-formation from the family revealed that severe bleeding had occurred, describing that blood from her neck had sprayed the ceiling, and that syncope had subsequently developed. Upon ex-amination at the emergency department, the patient’s general condition was good, she was conscious and vital signs were stable. A piercing injury 6x8 cm in size extending to subcutaneous and muscle tissue was present in zones 1 and 2 in the right upper area of the neck. Crepitation was present from the wound region to the thorax. Bleeding had been brought under control with a pressurized dressing. Since the lesion was long and wide, contrast computerized tomography (CT) of the neck was performed in order to vis-ualize the structures in the region. CT revealed air pockets around mediastinalstructures in up-per thoracic sections and between soft tissues in neck sections, pneumomediastinum and in-creased edematous density around mediastinal structures. No findings compatible with injury to vascular stryctures of the neck were determined (Figure 1a,b). Active bleeding from the laceration site was observed following tomography. The pa-tient was then taken for surgery for suspected large artery trauma. Median sternotomy was performed, and thearea where the innominate artery divides into the carotid and subclavian

ar-teries was accessed. The innominate artery was seen to be injured in this region. Exploration of the trachea due to pneumomediastinum revealed a small injury site in the trachea. The injuries in the innominate artery and trachea were repaired (Figure 2). The patient was intubated and moni-tored in the cardiovascularsurgery intensive care unit. No complications were observed on the first day postoperatively and the patient was extubat-ed. The patient was discharged without sequelae on the fifth day postoperatively.

DISCUSSION

Neck injuries are rare but potentially life-threat-ening conditions in pediatric emergency depart-ments. Half of neck injuries are penetrating and half are blunt (1).

Neck injuries may result from murder, suicide or accidents. Accidental neck injuries may involve contact with shards of glass, industrial accidents and contact between the neck and sharp objects (2). The injury in this case was due to a penetrat-ing object.

Three zones may be involved in neck injuries. Zone 1, between the clavicular and cricoid

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Başyiğit İ. et al. Life-threatening neck injury after a fall: A case report

Figure 1a,b: Air pockets around mediastinal structures and between soft tissues,

pneumomediastinum and increased edematous density around mediastinal structures at computerized tomographic imaging of the neck

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Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:34, Sayı / No:1 ₆₀

tilage, contains large arteries, proximal carotid arteries and pulmonary, trachea, esophagus, spinal cord, thoracic canal and major cervical nerve trunks. Zone 2, between the cricoid carti-lage and the angle of the mandible, contains the jugular veins, vertebral and common carotid ar-teries, the internal and external branches of the carotid artery, the trachea, esophagus, spinal cord, and larynx. Zone 3, between the angle of the mandible and the base of the skull, contains the pharynx, jugular veins, vertebral arteries and distal branch of the internal carotid artery (3). Since the neck contains numerous vitally impor-tant anatomical structures, life-threatening con-ditions are more common in neck injuries com-pared to other anatomical regions. Stroke and death occur after injury to the carotid artery in particular in neck injuries (4). Innominate artery injury and associated hemorrhagic shock were present in this case, but shock was successfully treated with early intervention and successful resuscitation.

The gold standard in terms of arterial damage in penetrating neck injuries is conventional angi-ography. Colored Doppler ultrasound, magnetic resonance imaging and helical spiral tomography can also aid diagnosis, depending on the health center involved. Tomographic angiography is an easily available, rapid, economical and non-inva-sive imaging technique with fewer personnel and equipment requirements. Studies have reported that multisection CT is 90% sensitive and 100%

specific in showing arterial injury, with a positive predictive value of 100% and negative predictive value of 98%. In addition to arterial damage, le-sions in other structures can also be revealed at CT imaging. Tomographic imaging is therefore the imaging technique of choice in neck injuries in many health centers (5). CT angiography was employed as a diagnostic technique in our case, and important information for patient manage-ment was obtained. However, active bleeding and extravasation were not detected at tomogra-phy. We think that the injured artery area closed due to compensatory vessel contraction and a buffering effect. Severe bleeding and syncope during the incident suggest probable arterial in-jury. Even if active bleeding is not determined at tomography in neck injuries, it is important for the possibility of arterial injury to be considered in the management of these patients.

While the mortality rate in all piercing injuries to the neck is approximately 11%, this rises to approximately 66% in injuries to vital structures. Timing of exploration after trauma is therefore critical. Emergency surgical exploration must be performed in the presence of active bleeding, pulsatile of expanding hematoma, failure to es-tablish airway integrity or shock (6).

Since penetrating neck injuries are rare, phy-sicians are not extensively experienced on the subject. It is also difficult to decide on protective surgery or exploration in such an anatomically dense region as the neck. Selective nonopera-tive treatment is generally preferred in zone 1 and 3 injuries and explorative surgery in zone 2 injuries. It is important in terms of surgical out-comes for surgery in those patients scheduled for it to be performed early. A well-organized dedicated trauma team is essential in order to attain optimal results (7). Although our case had zone 1 and 2 injury, since the injury extended to the innominate arteryand the patient was hemodynamically unstable, explorative surgery was performed and the patient improved with-out sequelae following successful surgery. Ad-ditionally, due to the medicolegal dimension of such incidents, legal reports must be prepared in cases of injury admitted to emergency depart-ments or health institutions. It is of great impor-Başyiğit İ. et al. Life-threatening neck injury after a fall: A case report

Figure 2: Post-operative appearance of the repaired

innominate artery and trachea (thin arrow–trachea, thick arrow–sutured state of the innominate artery)

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61 tance in forensic medicine to establish whether or not these cases are due to murder, suicide or accident.

Injuries to the neck region require rapid diagnosis and treatment due to the anatomical structure of

the area and the difficulties facing surgeons in neck surgery. Resuscitation and transport under appropriate conditions are important in the pre-hospital system. Such cases also need to be as-sessed in terms of forensic medicine, not forget-ting the medicolegal aspects.

Başyiğit İ. et al. Life-threatening neck injury after a fall: A case report

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