Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 19  |  Issue : 1  |  Page : 77-80

Anesthetic management of impalement thoraco-abdominal injury following fall from height in resource-poor settings


1 Department of Anesthesia and Intensive Care, College of Health Sciences, Benue State University, Makurdi, Nigeria
2 Department of Surgery, College of Health Sciences, Benue State University, Makurdi, Nigeria

Date of Web Publication7-Jun-2017

Correspondence Address:
Bassey E Edem
Department of Anesthesia and Intensive Care, College of Health Sciences, Benue State University, Makurdi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2276-7096.207586

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  Abstract 


Fall from height is a common cause of penetrating abdomino-thoracic injuries. These often require thoracotomies to treat. Thoracotomy requires lung isolation technique. Specialized endobronchial tubes and endobronchial blockers are ideally used in the technique. However, in resource-poor settings, these specialized tubes are often unavailable. We report how a conventional single-lumen endotracheal tube was used to carry out one-lung anesthesia for thoracotomy to repair an impalement thoraco-abdominal injury following a fall from height with good results.

Keywords: Endobronchial, endotracheal, fall, impalement, one-lung anesthesia


How to cite this article:
Edem BE, Bitto T, Eke B. Anesthetic management of impalement thoraco-abdominal injury following fall from height in resource-poor settings. J Med Trop 2017;19:77-80

How to cite this URL:
Edem BE, Bitto T, Eke B. Anesthetic management of impalement thoraco-abdominal injury following fall from height in resource-poor settings. J Med Trop [serial online] 2017 [cited 2020 Aug 14];19:77-80. Available from: http://www.jmedtropics.org/text.asp?2017/19/1/77/207586




  Introduction Top


Fall from height is a common cause of penetrating injuries closely following road traffic accidents and gunshots.[1] Most severe penetrating injuries occur in young males.[2] Palm wine tapping and harvesting of fruits from tall trees are the common commercial ventures that involve climbing. Traditional methods of climbing rarely provide for protection of the climbers and so, the risk of falling from height remains potent in traditional societies. Oil palm tree (Elaeis guineensis) can achieve a height of 20 m, making fall from such a real danger.[3] Another common cause of penetrating chest injury is arrow shot injury.[4]

Penetrating thoracic injuries require thoracotomies for repair. This often requires that a lung be collapsed to optimize access which involves the use of one-lung ventilation. Lung isolation is ideally done using specialized endobronchial tubes (EBTs) and endobronchial blockers. EBTs come as single lumen, for example, Magill, Gordon-Green, Macintosh-Leatherdale, and Brompton-Pallister tubes or double-lumen tubes (DLTs) which include Carlens, Bryce-Smith, Bryce-Smith-Salt, White, and Robertshaw. Other DLTs are Broncho-Cath ® (disposable plastic) and Silbroncho tubes (reinforced silicon). These have the advantages of ease of insertion and determination of position and ability to isolate, ventilate, or collapse lungs independently.[5]

However, in resource-poor settings, these specialized tubes are often unavailable. We report how the conventional single-lumen cuffed endotracheal tube (ETT) was used in the management of an impalement thoraco-abdominal injury with a good result.


  Case Report Top


VA, a 20-year-old male, palm wine tapper, presented at the Benue State University Teaching Hospital, Makurdi, Nigeria, with a 12 h history of fall from the oil palm tree. He landed on a stick (a dried tree branch) which pierced him from the back with an exit on the anterior chest wall medial to the left nipple. There was no loss of consciousness and no substantial external bleeding between the time of accident and presentation. He had a chest radiograph done [Figure 1] showing the shadow of the stick across the hemithorax] and a chest tube in situ before he was referred to our center.
Figure 1: Chest radiograph showing the stick in the thorax

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Physical examination revealed a young man, well nourished, lying supine with a dirty stick projecting out of the left side of the anterior chest. He had a pulse rate of 82 beats/min and a blood pressure of 124/80 mmHg with normal heart sounds. The chest expanded minimally on the left, bearing the stick with a respiratory rate of 26 cycles/min. Trachea was central. There were decreased breath sounds in the upper and middle lung zones on the left. No breath sounds were heard over the basal lung zone on the left chest wall. Breath sounds were normal on the right lung zones. Peripheral oxygen saturation (SpO2) in room air was 83%. The abdomen and other systems were essentially noncontributory. He was assessed American Society of Anesthesiologists class IE.

The following investigations were requested: urgent packed cell volume (39%), repeat chest radiograph, abdominal ultrasound scan, and four units of blood were cross-matched. The repeat chest radiograph and abdominal ultrasound could not be done as the Radiology Department was closed following its fumigation 2 days earlier.

The patient was well resuscitated as evidenced by the absence of external bleeding and stable vital signs throughout the stay at the Accident and Emergency Department. Intravenous (IV) fluids were given to maintain his fluid requirement as he was on nil per os.

The patient arrived to the theater 19 h after presentation. His baseline vital signs before anesthetic intervention were heart rate of 112 beats/min, noninvasive blood pressure of 130/90 mmhg, and SpO2 of 83%.

In the theater, the patient was preoxygenated to raise the SpO2 to 99%. He was premedicated with IV atropine 0.6 mg and pentazocine 60 mg. Anesthesia was induced with IV ketamine 150 mg, and muscle relaxation was achieved with suxamethonium. A cuffed ETT of size 8.0 mm, which was a size smaller than the estimated size for him, was inserted into the trachea with the patient in the right lateral position. This was advanced into the right main bronchus. Correct placement was ascertained by auscultation of the right chest in comparison to the left. This was improvised as an endobronchial intubation. The patient was paralyzed with pancuronium bromide 6 mg and manually ventilated on isoflurane 2% in 6 L/min 100% oxygen [Figure 2] and [Figure 3].
Figure 2: The patient with transthoracic stick injury showing entry wound

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Figure 3: The patient after intubation

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An antero-lateral thoracotomy was done through the left 11th intercostal space to the left 2nd intercostal space just lateral to the sternum avoiding the pericardium. A collapsed left lung with a lacerated parietal pericardium along with a 3 cm rent in the diaphragm at the costophrenic angle was found.

After the removal of the stick from the thorax [Figure 4], the ETT was deflated and withdrawn to the 21 cm mark on the tube. It was then re-inflated. The left lung was manually inflated slowly to fill up the thorax. It was inspected for leaks. When none was found, the tube was deflated again and advanced back into the right main bronchus. The left lung collapsed again to allow for easy closure of the thorax. A chest tube was re-inserted before final closure of the thorax. After this, the ETT was withdrawn again, and the left lung re-inflated. From the preintervention SpO2 of 83%, the oxygen saturation remained around 91–93%. It dipped once to 89%, and this was quickly reversed by hyperventilating him. However, after the re-inflation of the left lung, saturation rose to 100%. Intraoperative-estimated blood loss was 220 ml. The surgery lasted for 1 h 55 min.
Figure 4: The stick after removal at thoracotomy

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The volatile agent was switched off, and the patient's muscle paralysis was reversed with atropine 1.2 mg and neostigmine 2.5 mg. The patient was moved to the Intensive Care Unit (ICU) with the ETT in situ for close hemodynamic monitoring. On getting to ICU, SpO2 in room air was 89%. Oxygen was entrained into the ETT in the ICU (no ventilators), and SpO2 rose to 93% and then up to 100%. He was then extubated, and oxygen entrained by nasal prongs. He was discharged from the ICU 5 days later to the ward, and finally home on the 10th day.


  Discussion Top


Thoracotomy to remove an impaled stick in the thorax requires that the lung on that side of the thorax be collapsed. It is difficult to do this with the conventional ETT as its cuff is usually in the trachea resulting in the equal inflation of both lungs. EBTs easily overcome this by making provisions for inflation and deflation of the different lungs simultaneously or otherwise.[5] Anatomically, the right bronchus is more obtuse to the trachea than the left. This implies that a conventional ETT advanced blindly into the trachea will enter the right main bronchus. This theory was utilized in this case to solve the problem of the unavailability of EBTs. This would probably have been more difficult if the need was to collapse the right and not the left lung.

In addition, the right upper lobe (RUL) bronchus emerges a short distance from the right main bronchus. The narrow bronchial cuff of the EBT is designed to reduce the chance of it occluding the RUL bronchus as may occur where the conventional single-lumen ETT is used as in this case report. The “margin of safety,” defined as the length of the tracheobronchial tree over which a tube can be positioned without occluding a conducting airway, is very small with the conventional ETT and much larger with the EBT. We kept this in mind as we positioned the ETT, regularly auscultated, and continuously monitored oxygen saturation. Our position is in agreement with Purohit et al., who reported that in emergency situations, normal ETTs can be used for thoracotomies.[5]

We selected a tube smaller than the size for the patient to allow air in the lung to be collapsed to exit around the ETT. The use of tube of size smaller than the optimum for a patient can increase the work of breathing as it reduces gas flow. According to the Hagen–Poiseuille's law, reduction in tube radius decreases flow to the fourth power. This, however, was not a challenge to us as the patient was paralyzed and manually ventilated. The positive pressure ventilation ensured adequate air flow through the smaller tube.

One-lung ventilation causes ventilation-perfusion (VQ) mismatch which is aggravated by general anesthesia, mechanical ventilation, and neuromuscular blockade.[6] This causes hypoxemia. We instituted manual ventilation which allowed us to apply positive pressure or intermittently inflate the lung to improve oxygenation. We monitored hypoxemia using SpO2. Re-inflation of a collapsed lung is recommended whenever hypoxemia goes below the acceptable limit (SpO2 <90%).[7] Our patient had a short episode of saturation dipping to 89%, but was quickly reversed by hyperventilating him so that we did not have to interrupt surgery to re-inflate the collapsed lung for that reason.

To ease the withdrawal and advancement of the ETT, the cuff was deflated and inflated accordingly. This could increase the risk of tracheal irritation and cause postextubation croup. We minimized this by applying KY® lubricating jelly (Johnson and Johnson, Sézanne, France) before intubation. The patient was discharged home with no complaint of a sore throat.


  Conclusion Top


The ideal airway devices for thoracotomy/thoracostomy are EBTs and blockers. However, in emergency situations or resource-poor settings, single-lumen ETTs can be used successfully bearing in mind their margin of safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Onokpoya U, Ogunrimbi AB, Owotade FJ, Oyenusi AS, Ibrahim MH. Predictors of death from chest trauma in a resource-poor community in Southwestern Nigeria. Sahel Med J 2010;13:135-40.  Back to cited text no. 1
    
2.
Ohene-Yeboah M, Dakubo JC, Boakye F, Naeeder SB. Penetrating abdominal injuries in adults seen at two teaching hospitals in Ghana. Ghana Med J 2010;44:103-8.  Back to cited text no. 2
[PUBMED]    
3.
The Oil Palm Tree. Available from: https://www.en.wikipedia.org/wiki/Elaeis_guineensis. [Last accessed on 2016 Mar 29].  Back to cited text no. 3
    
4.
Eni UE, Na'aya HU, Madziga AG, Kwari YD. Arrow injuries in North Eastern Nigeria. Port Harcourt Med J 2012;6:350-7.  Back to cited text no. 4
    
5.
Purohit A, Bhargava S, Mangal V, Parashar VK. Lung isolation, one-lung ventilation and hypoxaemia during lung isolation. Indian J Anaesth 2015;59:606-17.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Rao SH, Natarajan S, Pallavi V. Anesthetic management of staged thoracoscopic repair of bilateral eventration of diaphragm in a neonate. Anesth Essays Res 2016-Apr; 10:118-21.  Back to cited text no. 6
    
7.
Yentis SM, Hirsch NP, Smith GB, editors. One-lung anaesthesia. In: Anaesthesia and Intensive Care A-Z an Encyclopaedia of Principles and Practice. 3rd ed. Edinburgh: Elsevier Limited; 2006. p. 383-4.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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