Accidental strangulation by electric rickshaw
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/MJDRDYPU.MJDRDYPU_55_17
Keywords: Clothing, female, morbidity
Injury by dupatta can have varied presentation ranging from injury to superficial tissues of the neck, fracture of hyoid, cervical spine injury, and laryngeal rupture to even carotid artery stenosis.[1] The long loose end of dupatta may get stuck in a moving wheel and cause serious injuries to the body. Deaths have been reported due to asphyxiation as a result of constriction of the neck by ligature strangulation.[2] The early recognition of injuries by a thorough examination and its conservative or surgical management can help reduce the morbidity and mortality.
A 25-year-old female had a fall when her dupatta got entangled in the wheel of an E-rickshaw [Figure 1] which constricted her neck. When brought to the emergency department, she had difficulty in breathing with stridor. She had a history of loss of consciousness at the time of fall. Her vital parameters were as follows. Heart rate – 90 beats/min, blood pressure – 116/82 mmHg, and oxygen saturation – 90% on room air. The patient had severe stridor and was shifted to Intensive Care Unit for further management. Arterial blood gas analysis showed PO2:82 mm of Hg, PCO2: 41.5, pH: 7.39, HCO3−: 24.1, and O2 saturation: 90%.
The neck and chest showed surgical emphysema. Since the patient was desaturating an attempt for intubation was done with in-line stabilization after giving 50 mg of propofol. The ENT specialist was ready with the tracheostomy and backing of cricothyrotomy set. The attempt to intubate failed due to extensive edema. Emergency tracheostomy was done, and a 6.5 mm cuffed tracheostomy tube was inserted as shown in [Figure 2] which is also showing the ligature mark. The neck showed a near circumferential prominent abrasion measuring 20 cm × 2 cm as ligature mark. The computerized tomography of the neck showed laryngeal edema and subcutaneous emphysema as shown in [Figure 3]. The patient was electively ventilated, regular nebulization was done with steroids, and antibiotic coverage was given. When attempt to decannulate was done the patient became restless and developed stridor, so the tracheostomy tube was reinserted. A fiberoptic laryngoscopy revealed paramedian vocal cords; hence, suspecting neurapraxia of the recurrent laryngeal nerve the patient was discharged on oral steroids, with tracheostomy tube in situ and regular follow-up for 6 months before thyroplasty.
The most common symptom of laryngotracheal trauma is hoarseness. Other presenting symptoms can include dysphagia, pain, dyspnea, hemoptysis, and symptoms of airway obstruction such as stridor and tachypnea. Other signs include drooling and cervical subcutaneous emphysema and crepitation.[3] Laryngeal rupture from strangulation with a scarf leading to cardiorespiratory arrest has been reported in literature. Severe laryngeal trauma and carotid artery damage can result in hemiparesis.[1] In our patient, she had hoarseness of voice, stridor, and surgical emphysema which suggested airway trauma since the patient was desaturating an attempt to intubate was done failing which emergency tracheostomy was done. Patients with tracheobronchial injury can have hemoptysis, subcutaneous emphysema, and tension pneumothorax. Intubation in such patients is frequently difficult because of anatomic distortion from paratracheal hematoma, associated oropharyngeal injury, or tracheobronchial injury itself.[4] Strangulation type injuries typically cause cartilage fracture without mucosal laceration. Associated arytenoid cartilage dislocation and recurrent laryngeal nerve injury can occur. The clothes line injury is one of the most severe forms of blunt trauma to the larynx.[5] Arytenoid subluxation and dislocation are extremely rare. It results in reduced mobility of the true vocal cord and incomplete glottis closure mimicking true vocal cord paralysis. Its incidence is unknown.[6] Goudy et al. found that of 236 patients admitted with aerodigestive tract injury only 8.9% (19 patients) were identified with cervical emphysema/crepitations caused by aerodigestive injury. Thus, indicating that it is a low yield sign of laryngotracheal injury.[7] Our patient when decannulated had a stridor. Fiberoptic laryngoscopy was done which revealed paramedian vocal cords suggesting abductor palsy. The tracheostomy tube was reinserted, and oral steroids were started. The patient was discharged after teaching appropriate care of the tracheostomy tube and a wait for at least 6 months before any definitive plan for surgery would be taken. The neuromuscular pedicle technique can be considered for any patient with bilateral vocal cord paralysis that has persisted for 6 months to a year. The ansa cervicalis nerve and its insertion into the appropriate strap muscle must be available for this technique.[8]
The low height of E-rikshaw, flimsy body open from all sides with small wheels makes it vulnerable for accident. The public awareness of the precautions to be taken, especially by females wearing traditional Indian dresses and dupatta needs to be emphasized. Laryngeal trauma by strangulation needs close monitoring because of the risk of airway compromise. 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.
[Figure 1], [Figure 2], [Figure 3]
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