https://orcid.org/0000-0001-6155-7302
Abstract
Penetrating neck injury (PNI), involving disruption of the platysma muscle, accounts for 10% of trauma cases and poses significant morbidity and mortality risks. This case report details the management of a 45-year-old male who sustained a 270-degree circumferential neck incision from an industrial accident. The patient presented with a deep neck laceration, severe blood loss, and hypovolemic shock. Pre-hospital care included intubation, oxygen supplementation, and fluid resuscitation. At the hospital, under general anesthesia, surgical interventions involved ligation of posterior neck vessels, hemostasis, muscle repair with Vicryl 1–0, drainage tube placement, and skin closure. Postoperative care included intensive monitoring, neurological assessments, and pain management. Effective management of severe PNI requires a multidisciplinary approach, combining prompt pre-hospital care, meticulous surgical techniques, and comprehensive postoperative management. Future research should focus on standardizing PNI management protocols and advancing surgical and diagnostic techniques to improve outcomes in similar critical cases.
Introduction
Penetrating neck injury (PNI), which is defined as a disruption of the platysma muscle, accounts for up to 10% of all trauma patients presented to the emergency room and is associated with high morbidity and mortality [1]. The incidence of PNI has evolved in conjunction with fast industrialization and the increasing prevalent usage of public transportation vehicles and precision industrial equipment, with a lack of adequate safety precautions as the main causes behind this, particularly among developing countries [2]. The various challenges in the assessment and treatment of penetrating neck injuries are attributed to the complex anatomy and viability of the area, which encompasses many vital vascular, respiratory, neurological and digestive structures [3]. Furthermore, the variance in the severity and the site of the penetration may also possess interventional challenges as the posterior neck injuries are significantly less prevalent than the more common anterior neck injuries, which are addressed by the ‘zonal’ distribution [4]. This necessitates a timely and efficient intervention by properly assessing the stability of airway and circulation, as well as the possibility of a skeletal or neurological injury prior to surgical intervention [5]. Importantly, there persists a need for a precise declaration on PNI management [6]. Our case report describes the case of a 45-year-old male with a sustained deep, 270-degree circumferential incision to the neck, tearing all the muscles in the neck and major vascular structures, including the posterior neck vessels, carotid arteries, internal and external jugular veins. This clinical case has been caused by an incidental industrial injury, specifically a penetrating trauma caused by a metal splinter obtained from the metallic section of a wood chopping axe.
Case presentation
The patient, a 45-year-old male, sustained a severe industrial accident resulting in a metal sheet cutting his neck up to bone depth, creating a 270-degree circumferential deep cut (Fig. 1). The initial injuries included laceration through all neck muscles, severance of posterior neck vessels, and damage to the carotid arteries and internal and external jugular veins (Fig. 2). Upon arrival at the scene, the patient was unconscious with severe blood loss, hypotension (80/60 mmHg), hypovolemic shock, a pulse of 108 bpm, and a respiratory rate of 18 breaths per minute. Pre-hospital management included intubation, supplemental oxygen, and intravenous fluid resuscitation with 1 unit of normal saline, which stabilized his blood pressure to 90/60 mmHg during transport (Fig. 3). At the hospital, the patient was stabilized under general anesthesia with isoflurane, receiving 8–10 units of blood transfusion. Surgical intervention involved ligation of the posterior neck vessels, suturing of bleeding points, end-to-end muscle repair with Vicryl 1–0, placement of a drainage tube in the posterior neck, and skin closure (Fig. 4). Postoperative management included detailed neurological assessments, regular wound inspections, continuous drainage monitoring, vital signs monitoring, pain management with NSAIDs, and respiratory system assessments. Moreover, nasogastric tube was inserted, and antibiotics were administered to prevent superinfection or sepsis. The patient’s prognosis remained guarded due to the severity of the injuries. Continuous monitoring and supportive care were essential in the post-weeks from the management. Further follow-up was required to assess long-term functional outcomes and the potential for rehabilitation.
Three pictures revealing the circumferential deep cut of the neck.
Posterior view showing the laceration of all neck muscles (The neck muscles include the platysma, digastric, stylohyoid, mylohyoid, geniohyoid, sternohyoid, omohyoid, sternothyroid, thyrohyoid, longus colli, longus capitis, rectus capitis anterior, rectus capitis lateralis, scalenus anterior, scalenus medius, scalenus posterior, rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis superior, obliquus capitis inferior, sternocleidomastoid, and trapezius).
Picture showing the depth of the cut with respect to the finger length.
Four pictures showing the surgical intervention that involved ligation of the posterior neck vessels, suturing of bleeding points, end-to-end muscle repair with Vicryl 1–0, placement of a drainage tube in the posterior neck, and skin closure.
Emergency department and surgical management summary
Upon arrival at the hospital, the patient was further stabilized under general anesthesia with isoflurane. The following interventions were undertaken:
Initial Stabilization:
Administered 8–10 units of blood transfusion to address severe blood loss.
Continued intubation and ventilation support.
Surgical Procedures:
Ligation of Posterior Neck Vessels: To control extensive bleeding.
Hemostasis: Suturing of all bleeding points.
Muscle Repair: End-to-end repair of severed neck muscles using Vicryl 1–0 sutures.
Drainage Placement: A drainage tube was placed in the posterior neck area to prevent fluid or blood accumulation.
Skin Closure: The skin was sutured to complete the closure of the wound.
Discussion
Severe penetrating neck injuries (PNI) demand swift, coordinated care due to the critical structures involved, including major blood vessels, nerves, and the trachea. This case underscores the importance of rapid pre-hospital and hospital interventions in stabilizing the patient and optimizing outcomes [7].
Pre-hospital care, including intubation, oxygen supplementation, and fluid resuscitation, was essential for stabilizing the patient. Intubation ensured airway security and adequate oxygenation, while oxygen supplementation prevented hypoxia. Fluid resuscitation addressed hypovolemic shock by restoring blood volume and maintaining perfusion pressure.
Upon hospital admission, the patient’s severe hypovolemic shock required aggressive resuscitation with blood transfusions and ventilatory support. A tracheostomy was recommended for long-term airway management, reducing complications and ensuring airway patency [8].
Surgical intervention involved critical steps: ligating posterior neck vessels to control life-threatening bleeding, meticulous hemostasis to prevent hematoma and maintain stability, and repairing severed neck muscles to restore anatomical function. Placement of a drainage tube helped prevent fluid accumulation and related complications, and skin closure protected the wound from external contaminants [9].
Postoperative care focused on intensive monitoring, including neurological assessments, vital signs, and drainage management. Nutritional support through a nasogastric tube and antibiotic therapy were crucial for recovery and infection prevention. Pain management with NSAIDs and respiratory assessments further supported the patient’s recovery [5, 10].
Challenges in managing PNI, particularly posterior neck injuries, highlight the need for tailored approaches and emphasize the importance of standardized protocols. Future research should explore novel surgical techniques [4], materials, and advancements in imaging to improve assessment and treatment [11]. Developing clear guidelines and improving diagnostic capabilities will be essential for enhancing patient outcomes in severe PNI cases.
Conclusion
This case report highlights the critical management of a severe penetrating neck injury sustained by a 45-year-old male during an industrial accident. The initial emergency response and subsequent surgical interventions, including extensive blood transfusions, ligation of the posterior neck vessels, muscle repair, and placement of a drainage tube, were pivotal in stabilizing the patient. Despite the severity of the injury, the patient’s immediate post-operative period was managed successfully through meticulous monitoring and supportive care. This case underscores the importance of a multi-disciplinary approach in handling complex penetrating neck injuries, involving prompt pre-hospital care, effective surgical techniques, and comprehensive post-operative management.
Conflict of interest statement
None declared.
Funding
None declared.
References
Koruga N, et al. Posterior penetrating injury of the neck: a case report.
Aljohani K, et al. Penetrating neck injury: double jeopardy of a complex aerodigestive dilemma.
