Management of cut-throat injuries

Introduction Neck injuries are potentially dangerous and require emergency treatment. Th e location of the injury can predict risk and management. Open or incised injuries or those resembling incised injuries in the neck infl icted by sharp objects such as razor, knives, or broken bottle pieces or glasses that may be superfi cial or penetrating in nature may be described as ‘cut-throat injuries’ (CTIs) [1–3]. Th is may result from accident, homicide, or a suicide attempt. CTIs are potentially life threatening because of the many vital structures in this area. Th ere may be a possibility of severe hemorrhage from damaged major blood vessels, air embolism, or airway obstruction. Th e common causes of CTIs in this part of the world are suicide attempts. Family problems, psychiatric illness, unemployment, and poverty may be the triggering factors in suicide attempts. Th e motives for homicide may include land-related disputes, sexrelated crimes, familial disharmony, etc. Exposed hypopharynx and or larynx, hemorrhage, shock, and asphyxia from aspirated blood are the common causes of death following a CTI. It is known that appropriate measures can save lives in the majority of cases [3]. Prevention of these complications depends on immediate resuscitation by securing the airway by tracheostomy or intubation. Th e value of tracheostomy in the management of CTI has been highlighted in the literature [4,5]. Prompt control of external hemorrhage, blood replacement, and prompt intervention or operative treatment should be performed when indicated. All patients who have attempted suicide should undergo a psychiatric evaluation. Th is is because the act of suicide is a sign of an underlying mental illness and there may be a possibility of a second attempt. Victims of homicidal CTIs need psychological support to overcome the trauma to their psyche, which may remain long after the neck wounds have healed [6]. Management of cut-throat injuries Zafarullah Beigh, Rauf Ahmad


Introduction
Neck injuries are potentially dangerous and require emergency treatment. Th e location of the injury can predict risk and management. Open or incised injuries or those resembling incised injuries in the neck infl icted by sharp objects such as razor, knives, or broken bottle pieces or glasses that may be superfi cial or penetrating in nature may be described as 'cut-throat injuries' (CTIs) [1][2][3]. Th is may result from accident, homicide, or a suicide attempt. CTIs are potentially life threatening because of the many vital structures in this area. Th ere may be a possibility of severe hemorrhage from damaged major blood vessels, air embolism, or airway obstruction. Th e common causes of CTIs in this part of the world are suicide attempts. Family problems, psychiatric illness, unemployment, and poverty may be the triggering factors in suicide attempts. Th e motives for homicide may include land-related disputes, sexrelated crimes, familial disharmony, etc. Exposed hypopharynx and or larynx, hemorrhage, shock, and asphyxia from aspirated blood are the common causes of death following a CTI. It is known that appropriate measures can save lives in the majority of cases [3]. Prevention of these complications depends on immediate resuscitation by securing the airway by tracheostomy or intubation. Th e value of tracheostomy in the management of CTI has been highlighted in the literature [4,5]. Prompt control of external hemorrhage, blood replacement, and prompt intervention or operative treatment should be performed when indicated. All patients who have attempted suicide should undergo a psychiatric evaluation. Th is is because the act of suicide is a sign of an underlying mental illness and there may be a possibility of a second attempt. Victims of homicidal treatment. Aich et al. [7] studied 67 cut-throat cases; 47 were males and 20 were females, between 7 and 73 years of age (mean 28.82±11.38 years). Th e majority of victims were young adults [41 (61.19%)] between 21 and 30 years of age, 52 (77.61%) were from a rural community, and 53 (79.10%) belonged to the low socioeconomic class. In our study of 26 patients, the majority were males (88%) from rural areas (61%), and patients in the age group 36-50 years were most vulnerable, similar to the results of the above-mentioned study. Adoga et al. [8] published a Assessment of patients with CTI begins with the ABCs of resuscitation, that is, checking the airway, and evaluating the patient's breathing and circulation. Resuscitation of individuals should be commenced immediately.
When the victims present to hospital, the anesthesiologist secures an uncompromised airway and ensures that the patient is breathing and the otorhinolaryngologist assesses the injury and surgically repairs the severed tissues with the aim of restoring breathing, swallowing, and phonation. The psychiatrist provides adequate care and supervision during and after the surgical repair of severed tissues.

Materials and methods
Th is retrospective study was carried out in the Department of Otorhinolaryngology and Head Neck Surgery, Government Medical College, Srinagar, J&K, India, and included 26 patients with CTIs who were brought to our department for treatment. Informed consent was obtained from the relatives of all patients for this study. Th is study was approved by the institutional ethics committee. All patients were resuscitated; depending on the condition of the patient, tracheostomy was performed when required and blood transfusion was administered in patients who had severe bleeding. After stabilizing the vitals, the wound of the patients was examined and depending on the condition of the wound, primary or secondary repair was performed. Subsequently, the cause of the CTI was enquired. Patients who made suicidal attempts were referred to the psychiatrist for evaluation.

Results
Th e results are displayed in Tables 1-5.

Discussion
CTIs are reported scarcely in the medical literature. CTIs and associated deaths are not uncommon in our society. Th ere are reports in the medical literature of CTIs from West Africa on the complication and principles of management of such wounds, with an emphasis on the forensic implications [2]. An article on open neck injuries stressed on surgical airway problems [5]. In our study, 26 CTI patients were brought to the Department of ENT and Head Neck Surgery, Government Medical College, Srinagar, for    [6]. Nock et al. [14] concluded that mental disorders predict suicidal behaviors similarly in both developed case series of three patients with CTIs; all three of these patients had attempted suicide. In terms of the cause of injury in our study, attempted suicide was the cause in 58%, homicide in 38%, and accidental in 3% of patients. Mohanty et al. [9] studied 588 suicide victims, fi nancial burden (37%) and marital disharmony (35%) were the principal reasons for suicide attempts. In our study, the causes of suicide were psychiatric illness, unemployment, and family troubles, which was in agreement with the above study. Th e causes of homicidal injuries were landrelated disputes and sex-related crimes. One patient had an accidental CTI because of a fall on broken glass. Modi and Pandy [10] observed that in India, suicidal wounds of the throat are rare. In contrast, CTIs were reported to be caused by suicide attempts in the majority of cases in western studies [11,12]. In our study males with CTI were more in number then females with CTI.
As CTI is a major neck injury, most of the victims were sent to the nearest available medical facilities as early as possible. Majority were referred to the tertiary hospital for appropriate intervention within 24 h. Poor communication, inadequate fi rst-aid knowledge and facilities, and lack of skilled manpower in peripheral centers were responsible for delayed presentation to hospital. Very few had been managed properly outside. A number of victims presented with an open wound and active bleeding. Onotai and Ibekwe [13] concluded that CTIs require a multidisciplinary approach and can be managed with a better prognosis if patients present early to the hospital and receive prompt attention.
In our study, the majority of patients (65%) had injury in the center of the neck and a cut was the most common type of injury. Five patients had only skin and soft tissue injury, 19 patients had skin, soft tissue, and larynx/pharynx injury, one patient had injury to the skin, soft tissue, and major vessel (external jugular vein), and one patient had injury to the skin, soft tissue, larynx/pharynx, and major vessel (left common carotid and internal jugular vein). In our study, primary repair of the wound was performed in 24 patients, out of whom nine patients required tracheostomy in view of upper respiratory obstruction. Secondary repair of the wound was performed in two patients; both these patients had a necrotic wound and upper respiratory obstruction. Tracheostomy was performed in both these patients. In all patients who had attempted suicide, psychiatric evaluation was sought. Th is was because the act of suicide is a sign of an underlying mental illness and there may be a possibility of a second attempt. A study reported 25% of patients as having made a second attempt at suicide Cut-throat injury during repair.

Fig. 1
Suicidal cut-throat injury. and developing countries. Our study showed that 66% of attempted suicide cases had some form of psychiatric ailment; 33% had major depression. Two patients had shaizophrenia which includes a patient with history of 3 suicidal attempts. Venkatachalam et al. [15] reported on a case of a penetrating cervical tracheal injury because of 'chain snatching' in a young female. Th e young female patient presented to the Emergency Department with a bleeding neck wound. Orotracheal intubation was performed after resuscitation, indicating a transected trachea. Th ere was no injury to the major vessels or nerves; thus, the wound was debrided and closed in layers and a tracheostomy tube was placed through the transected trachea. Postoperatively, the patient was ventilated for 72 h, after which she recovered completely. In our study, 20 patients out of 26 achieved full recovery without any permanent defect, four patients recovered with some permanent defect (three patients had hoarseness of voice and one patient had upper airway stenosis/web formation), and two patients died, of whom one 15-year-old male with a homicidal injury had a stab injury on the left side of the neck, with injury to the left common carotid and the internal jugular vein; in this patient, 6 U of blood were transfused and major vessels were ligated. He developed hemiplegia and hypotension in the postoperative period. Subsequently, the patient went into shock and died on the second day of admission to the hospital. Th e second patient who died had an injury because of attempted suicide; this patient was a 50-year-old man with a cut in the center of the neck. He died because of cardiac arrest on the second day of admission. Hospital stay was prolonged in tracheostomized patients and patients in whom additional wound care was needed (Table 4).