Difficult Endotracheal Intubation as a Result of Penetrating Cranio-Facial Injury by an Arrow

Abstract

Penetrating injury of the face and airway may make endotracheal intubation difficult or impossible. We report the case of a patient who attempted to commit suicide with a crossbow. Surgery under general anesthesia was required to remove the arrow. The oral intubation route was impossible, and a fiberoptic nasal intubation under local anesthesia was performed. Case Report A 42-year-old man attempted to commit suicide using a crossbow arrow. He positioned the weapon vertically under his chin and pressed the trigger. At his arrival at the hospital, the patient was fully conscious and the neurological and systemic physical evaluations were normal. Craniofacial radiographs and a tomodensitometric examination were performed. The heavy carbon arrow was 60 cm long and 8 mm in diameter. The missile entered under the chin and went through the tongue, the left nasal cavity, and the ethmoid, penetrated the brain between the two frontal lobes, and came out of the skull to the left of the transverse cerebral venous sinus (Fig. 1).Figure 1: After intubation; a, end of the arrow whose sharp tip was removed; b, bottom and feather of the arrow.General anesthesia with endotracheal intubation was required to remove the arrow. The challenge was in establishing a secure airway. The patient had his breakfast immediately before the suicide attempt and was therefore considered to have “full-stomach.” The duration between induction of general anesthesia and securing the airway had therefore to be as short as possible. The opening of the mouth was limited to one centimetre with the arrow in its middle and mobilization of the mandible impossible. The introduction of a Guedel airway was impossible. The risk of failure of manual ventilation via a face mask after the induction of general anesthesia was therefore important. The missile fixed the tongue. An attempt to introduce a laryngoscope laterally was terminated because of pain. Tracheotomy seemed difficult because the arrow’s base was in the middle of the surgical field. Nasotracheal intubation is usually not performed in cases of basal skull fracture with communication between nasoethmoidal cavities and meninges through a damaged dura mater. The arrow obstructed the left nasal cavity but the nasal septum remained in place. Fiberoptic-guided intubation through the right nasal cavity under topical anesthesia with 5% lidocaine spray was performed. A size 8 endotracheal tube was readily guided into the trachea and the cuff was inflated. General anesthesia was induced with IV sufentanil and propofol. The patient was very cooperative during the whole process. The arrow was removed through a small frontal craniotomy without major hemorrhage; the integrity of the transverse cerebral venous sinus was confirmed and dura mater was repaired. The patient was transferred to the surgical intensive care unit. A new tomodensitometric examination demonstrated the absence of cerebral hemorrhage and edema. The tracheal tube was easily removed 36 h later. Despite the spectacular appearance of the injury on admission to the hospital and the occurrence of streptococcal meningitis, the patient fully recovered and was discharged from the hospital. Discussion Self-inflicted crossbow injuries to the head are seldom reported, and these have not been related to difficult endotracheal intubation (1–4). Despite a relatively low velocity (compared with gunshots), the sharpness and propulsion force of the crossbow may be sufficient to enable penetration of the skull at short range. The major risk is a direct injury of cerebral parenchyma, and a vascular injury is sometimes revealed at the removal of the foreign body (4). In our case, a lesion of the transverse cerebral venous sinus was suspected, and therefore general anesthesia was required in case a large craniotomy was needed to repair it. In our patient, application of a face mask was impossible, and therefore the life-threatening “can’t intubate, can’t ventilate” situation was a risk if anesthesia was started before securing the airway. Fiberoptic intubation under spontaneous respiration was considered the best technique in this case (5). It does not require moving the head of the patient which was difficult and painful in our case. In our patient, the use of the fiberscope was a life-saving procedure through rapid airway protection by transnasal intubation when other routes and techniques were not possible. A fiberscope should be available for such emergencies in every operating room. Because fiberoptic intubation is seldom performed by most anesthesiologists, various approaches for learning and applying fiberoptic endoscopy have been proposed (6).