A report on a case of accidental neck strangulation and its anesthetic concerns

Sir,

This report presents an interesting case of injury to a child when her neck dupatta (long neck scarf) got entangled in the moving spokes of a fodder-cutting machine. This resulted in extensive (75%) scalp avulsion, de-gloving injury of both the forearms and a prominent constrictive abrasion on the neck caused by the dupatta. Anesthetic management is challenging in such a case because of a wide spectrum of injuries, ranging from insult limited to superficial neck tissue to fracture of laryngeal cartilages and cervical spine.

The dupatta (stole) is a popular traditional wear in the Asian subcontinent. The long loose end of the dupatta may get stuck in a rotating machine and cause serious injuries to the body.[1,2] Accidental strangulation due to household devices or machinery is extremely uncommon, and we report such a rare occurrence and its management.

A 12-year-old female sustained injury by a fodder-cutting machine when her neck dupatta got entangled into the spokes of the moving wheel. She was pulled towards the machine, and the dupatta she was wearing constricted her neck. Before stopping the machine, she attempted to push herself back taking support of the machine with both her hands, which too got stuck into the machine. This resulted in extensive (75%) scalp avulsion [Figure 1], de-gloving injury of both the forearms and a prominent constrictive abrasion on the neck caused by the dupatta [Figure 2].

Figure 1.

Extensive (75%) scalp avulsion

Figure 2.

Ligature mark on the neck caused by the dupatta

In the Emergency Department, she was resuscitated with warm crystalloids through two large-bore peripheral cannulas in lower limbs and shifted to the operating room. She had Glasgow Coma Score (GCS) of 15/15, and CT head was normal. Her vital parameters were as follows: heart rate, 140/min; blood pressure, 88/50 mm Hg; and saturation, 99% on room air. Larynx and airway were found within normal limits by an ENT specialist.

Intubation was done with in line cervical immobilization with backup cricothyrotomy and surgical tracheostomy for the difficult airway scenario. Post-induction Arterial blood gas analysis (ABG) showed a pH of 7.376; pCO₂, 25.3; HCO₃, 14.8; and Hb, 4.4). The patient was administered 2 units of packed cells, 2 units of fresh frozen plasma and 2 units of platelets. Sodium bicarbonate and mannitol were administered to prevent crush-injury-induced damage. The patient was extubated under fiber-optic guidance, which revealed punctate hemorrhages of anterior tracheal wall but no tracheobronchial rent [Figure 3].

Figure 3.

Fiber-optic examination revealed punctate hemorrhages of anterior tracheal wall but no tracheobroncheal rent

Accidental strangulation by a neck dupatta getting stuck into a fodder-cutting machine is in itself a rare mode of getting injured. Reports of a dupatta getting stuck into wheels of automobiles and spokes of rotating machines are found in the literature. Such an injury may have varied presentation, ranging from injury to superficial tissue of the neck to fracture hyoid, cervical spine injury, laryngeal rupture or even carotid artery stenosis.[3] Concerns in the case of this patient were cervical spine injury, laryngeal trauma, extensive scalp avulsion and crush injury to forearm.

For suspected cervical injury, hard cervical collar was applied and manual in line stabilization done. Patients with tracheobronchial injury can have hemoptysis, subcutaneous emphysema or tension pneumothorax, all of which were absent in our patient. Intubation in such patients is frequently difficult because of anatomic distortion from paratracheal hematoma, associated oropharyngeal injuries or tracheobronchial injury itself.[4] Immediate operative backup was kept ready. Bronchoscopy, being confirmatory for diagnosis,[5] ruled out tracheal injury in our patient.

Scalp avulsion resulting from hair entrapment in the wheels of a rotating machine is a rare but a severe injury. Scalp lacerations may result in major blood loss, especially in children because of the scalp's generous blood supply.[6] Our patient had 75% of scalp avulsion and Hb of 4.4 gm/dL; rapid cessation of bleeding, wound compression and aggressive fluid resuscitation were done. To prevent myoglobin-induced renal failure; intravascular fluid expansion, osmotic diuresis by mannitol, alkalization of the urine, and urine output of 1 mL/kg were ensured in our patient, like for any other crush injury.[7]

Scalp avulsion can cause the child to bleed to death, so it should be aggressively managed. A ligature mark on the neck should incite for careful extubation under fiber-optic visualization. In a hospital setting, knowledge of the mechanism of injury, anticipation of likely underlying injuries, and timely aggressive management are the key to successful outcome.

Raising the level of awareness among the general population about such dupatta injuries, simple techniques like tying both the ends of the dupatta together, promoting the use of aprons while working near any machinery and incorporating safety guards in equipment with spokes can decrease the incidence of such injuries.