Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 99-101

Miraculous escape in a case of penetrating neck injury by arrow


1 Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Cardiothoracic and Vascular Surgery, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India

Date of Submission23-Nov-2020
Date of Decision15-Mar-2021
Date of Acceptance18-Mar-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Raja Lahiri
Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_160_20

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  Abstract 


Penetrating neck injuries due to arrowheads have become extremely rare in most of the nations. Although the basic principles of management remain the same as that of other penetrating injuries, certain extra precautions need to be taken while managing such cases. A 56-year-old man who suffered from an arrow injury to the neck had a lucky escape from any significant injury to vital structures. The patient underwent successful surgical removal of the arrowhead. Knowledge of the various principles of management of such injuries is key to a successful outcome.

Keywords: Arrowhead, missile injuries, neck injuries, penetrating


How to cite this article:
Lahiri R, Mahapatra SS. Miraculous escape in a case of penetrating neck injury by arrow. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:99-101

How to cite this URL:
Lahiri R, Mahapatra SS. Miraculous escape in a case of penetrating neck injury by arrow. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Dec 1];8, Suppl S1:99-101. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/99/324938




  Introduction Top


Penetrating neck injuries due to arrowheads have become extremely rare in most of the developed nations and many of the developing countries. Such injuries are mainly reported from tribal regions, where modern firearms are still not in vogue.[1] The presence of vital structures including the airways make management of such injuries difficult at times. Successful outcome requires experience and expertise along with good teamwork. We present a case of an arrowhead injury to the neck where the patient had a miraculous escape from lethal injury to any vital strictures. We also discuss the essentials of management of such injuries.


  Case Report Top


A 56-year-old man living in a tribal region suffered from an arrow injury to the neck on the left side as a result of some altercation. The patient reported bleeding from the site following injury and pain at the local site. There was no history of loss of consciousness. The patient was taken to the nearest primary health center, where the stump of the arrow was carefully chopped off, taking care not to disturb the arrow. The patient was then referred to a tertiary care center with vascular surgery facilities. On arrival, the patient was stable with no active bleeding and no gross swelling over the neck. The stump of the arrow was seen on the left side of the neck, in the posterior triangle [Figure 1]. X-ray showed a wide metal arrowhead, reaching up to the midline. The patient was taken to the operation room and explored under general anesthesia. Minimum neck manipulation was done during endotracheal intubation. An incision was made anterior and parallel to the left sternocleidomastoid muscle, and the neck vessels were dissected. The metal arrowhead was seen posterior to it [Figure 2]. On retraction of the vessels, the tip was found lodged in the tracheoesophageal groove. There was a partial thickness tear in the esophagus; however, the mucosal continuity was maintained. Trachea was spared of injury. The tip was gently manipulated and delivered out of the wound and pushed anteriorly [Figure 3]. The bamboo shaft was divided so as not to introduce the external part of the shaft into the wound. The metal head was delivered through the surgical wound anteriorly. The esophageal injury was repaired with interrupted polyglactin sutures. The wound was washed and primarily closed. The patient was extubated on table and orally allowed the next day. The patient made an uneventful recovery.
Figure 1: Patient at presentation showing a bamboo shaft in the posterior triangle. No active bleeding or swelling seen

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Figure 2: On dissection of the carotid triangle and retraction of the vessels, the metallic tip (yellow arrow) is seen deep to the vessels, lodged in the tracheoesophageal groove. The bamboo shaft (green arrow) is seen outside

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Figure 3: Successful delivery of the arrowhead outside the surgical wound. At this point, the part of the shaft lying outside is divided so as to minimize wound contamination

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  Discussion Top


Although gunshot wounds are the most common neck penetrating injuries in the developed world, this finding is not the case in the developing world, particularly in tribal regions. Patients with arrow wounds to the head and neck usually present with either the entire arrow or part of it inside or with the weapon removed by bystanders or relatives. The former is the best situation for a surgeon, as well as for the patient, as the weapon can be carefully removed without causing further injury. As opposed to other impalement injuries, arrowheads are specifically designed to cause more injury during withdrawal. As in our case, a thin bamboo or wooden stick is what is seen outside and may create confusion. Hence, no attempt should be made to remove the impaling object unless done by a surgical team in a controlled environment.

In cases where the arrow has been removed or attempted removal before presentation to medical care, the extent of underlying injuries may not be evident from outside. If stable, it is better to go for an imaging, viz., computed tomography or magnetic resonance imaging (MRI), to assess the nature of injury and decide upon the procedure required. However, one has to be sure that there are no retained metallic fragments in the wound, before taking the patient for MRI. Some injuries may require exploration upfront. Late presentation may require debridement of the injured areas. Often vascular injuries present late as arteriovenous fistulae or pseudoaneurysm. Sometimes, the attempt to removal itself can be catastrophic and life-threatening. Rarely, retained bits of metal from arrowhead may present late with foreign body granulomas.[2]

The assessment and management of penetrating trauma neck have traditionally been classified into three anatomical zones, described by Monson et al. in 1969.[3] Zone 1 extends from clavicles to cricoid, zone II from cricoid to angle of the mandible, and zone III from angle of the mandible to skull base. The initial assessment and management are based on the ATLS principles and ensuring that no attempt to remove the foreign body is made.[4] If the platysma is intact, then, by definition, the wound is superficial. If the platysma is violated, then it is a penetrating neck injury and the patient's signs and symptoms govern how to proceed with the management. As the neck contains many vital structures, injuries of which can be life-threatening if not managed rapidly, there are certain signs that mandate an urgent exploration. These are shock, pulsatile bleeding or expanding hematoma, palpable thrill or audible bruit, airway compromise, stridor, subcutaneous emphysema, or neurological deficits.[5] Airway management is crucial in such cases and strategy modifications, e.g., use of fiberoptic-guided intubation or tracheostomy may be required in such cases.

During surgical exploration of arrow injuries to the neck, it is vital to secure the airway even if it may be potentially compromised.[6] Once the airway has been secured and after ensuring adequate ventilation, we proceed to take control of the hemorrhage. Only after taking adequate vascular control, we look at the extend of injury and attempt to remove the arrowhead. If the arrowhead can be safely delivered through a counter-incision (as in our case), it is most preferable. However, we should take care not to excessively manipulate the tip while taking it out as it may cause further injury. Moreover, care should be taken not to reintroduce the contaminated shaft lying outside into the wound while delivering. More commonly, it is not possible to deliver it with this technique, owing to the direction of penetration of the projectile. In such cases, we need to widen the entry wound and carefully dissect and retract the deeper structures and make a wide enough aperture to pull out the arrow head without causing further damage. Otherwise, if feasible, the entire tract can be laid open by dissecting all the overlying structures.[7] Adequate debridement is usually necessary, and patients should receive prophylaxis against Clostridium spp. if not already immunized.

It cannot be reiterated more that no attempts should be made to remove the arrowhead unless done by an expert. In our case, we were fortunate that no such attempt was made. One blade of the arrow was abutting the carotid vessels, another had partially sliced the esophagus, and the tip was just short of penetrating the trachea. Any careless attempt of removal would have been fatal for the patient.


  Conclusion Top


Penetrating arrowhead injuries to the neck are not commonly seen in most of the world. Although the basic principles of management remain the same as that of other penetrating injuries, certain extra precautions need to be taken while managing such cases. Timely and expert management along with public education can avert catastrophic complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aremu SK, Dike B. Penetrated arrow shot injury in anterior neck. Int J Biomed Sci 2011;7:77-80.  Back to cited text no. 1
    
2.
Nwawolo CC, Asoegwu CN. Experience with managing penetrating anterior neck injuries in Lagos, Nigeria. J West Afr Coll Surg 2017;7:1-23.  Back to cited text no. 2
    
3.
Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma 1969;9:987-99.  Back to cited text no. 3
    
4.
Adamu A, Ngamdu YB. Management of penetrating arrow neck injury: A report of two cases. MAMC J Med Sci 2020;6:63-7.  Back to cited text no. 4
  [Full text]  
5.
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and management. Ann R Coll Surg Engl 2018;100:6-11.  Back to cited text no. 5
    
6.
Mu˜noz-Cruzado V, Segura-Sampedro JJ, Marchal Santiago A, López Bernal F, Pareja Ciuró F, Padillo Ruiz FJ. Penetrating neck trauma caused by an arrow in attempted suicide. Med Intensiva 2017;41:379-81.  Back to cited text no. 6
    
7.
Nepal A, Joshi RR, Bhandary S, Mathur NN, Roka YB, Yadav R. Penetrating neck injury by an arrow: A paradigm of age old assault. Nepal Med Coll J 2010;12:58-60.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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