The access limited the direct view into the posterior mediastinum, but our idea was to reduce any patient rotation to a minimum, so that the injury to the vascular wall of the aorta was not compounded. After ensuring that the tip of the blade did not penetrate completely through the aortic vessel wall, but only bordered the surface of adventitia of the aortic arch, the first assist removed the knife. Subsequently to the removal of the blade, no hemorrhage to the pleural cavity was noted, and at this stage the decision to leave an additional drain in the left pleural cavity and to close the thorax was made.
Afterwards the neck injury exploration was begun. To extend the post-injury wound a cut along the medial edge of the right sternocleidomastoid muscle was applied. During the dissection towards the trachea no damage to the vital anatomic structures was noted.
However, after the deep layers behind the trachea were explored, tangential damage to the tunica adventitia of the esophagus was discovered. The esophageal injury was attended to with simple monolayer interrupted stitches. A Redon drain was left in the attended injury site, which was removed on the second day after the surgery. The upper drains from the pleural cavity were removed on the third day after surgery, and the left lower drain on the second day.
The patient was discharged to a psychiatric hospital on the seventh day after the surgery. During the follow-up visit on the tenth day the stitches were removed, and no complications were noted. These injuries are unique and challenging, especially those which penetrate to the thorax cavity. The abbreviated surgical exploration is also in many cases insufficient to answer whether an extended surgical procedure is necessary.
According to Roon and Christensen, the neck can be divided into three zones: zone I — between the sternal notch and the cricoid cartilage; zone II — between the cricoid cartilage and the lower border of the mandible; and zone III — between the lower border of the mandible and the base of the skull. According to international literature, the most frequent site of injury is the aerodigestive tract, followed by the major vascular structures and nerve injuries [ 2 , 3 ].
Although zones I and III are protected by bones, penetrating trauma to this area is more dangerous than to zone II because of the proximity of the thorax and skull base. When lack of symptoms and absence of neck swelling do not exclude the possibility of underlying serious injuries, the knowledge of the common consequences of each zone of injury can provide some idea of the possible extent of the internal damage.
Unstable patients usually require an urgent operation due to severe bleeding or concomitant injuries. Hemodynamically stable patients require extended diagnostic procedures to plan the final surgical procedure. In this particular case, where our patient showed full cardiopulmonary viability, extended radiological diagnostics the CT scan of the neck and thorax allowed detailed visualization of the trajectory of the blade, which was observed to be 14 cm in length and penetrated into the posterior mediastinum, bordering the vessel wall of the aorta.
This diagnostic method also made the concomitant injury of the bilateral pneumothorax apparent, although it did not reveal the damage to the tunica adventitia of the esophagus in the cervical region.
This case is extremely unusual for at least two reasons: firstly, the self-inflicted stab wound is an uncommon method of suicide attempt, and secondly, to date we have not come across an analysis of a wound penetrating from the neck region through the central mediastinum to the posterior mediastinum, reaching the vessel wall of the aortic arch and not damaging any vital structures in accessible databases of international literature. Medical management in such cases, due to their infrequency, requires, besides the individual approach, excessive caution and control.
No unified recommendations for such injuries have been established yet [ 4 , 5 ]. The importance of using a spiral CT scan in hemodynamically stable patients is underlined in the international literature, commonly combined with the oral administration of a water-soluble contrast medium in the case of esophageal damage, or with angiotomography in the case of vessel damage [ 4 , 5 ].
This diagnostic method in most cases expedites the decision involving the approach method and the extent of the final surgical procedure, provides information on the anatomic ratios of the foreign body to the vital organs, and allows one to foresee the possible consequences of removal of the foreign body.
Moreover, it can make smaller injuries apparent, which when not discovered can contribute to the development of long-term complications, such as mediastinitis, mediastinum abscess, or dissecting aneurysm of the aortic arch vessels [ 4 ].
In the described case, however, the CT scan did not reveal the intraoperatively discovered damage to the outer esophagus wall. We have to remember that patients with retained blades and vessel injuries can be hemodynamically stable on admission, because the blade acts as a local tamponade. Simple descriptive statistics were used to analyze the data.
Fifty-four patients with a presumed suicide attempt by self-inflicted stabbing were admitted during the study period. Ages ranged from 19 to 82, with an average of 45 years of age. Patient demographics can be found in Table 1. The most commonly used illicit substances included: benzodiazepines 9 , opiates 8 , cocaine 5 , cannabis 5 , and barbiturates 2. Eight patients overdosed on medications such as insulin, methylphenidate, selective serotonin reuptake inhibitors, aspirin, acetaminophen, ibuprofen, trazodone, or benzodiazepines.
The most common site of peripheral injury was the wrist 8 patients , all of which necessitated operative intervention. The overall sites of injury and their management are summarized in Table 2. Of the 18 stab wounds to the neck, all were located in zone two. Seven underwent ligation of internal, external, or both jugular veins.
Two patients underwent tracheal laceration repair with one individual requiring tracheotomy due to thyroid cartilage fracture. Three patients with penetrating neck injury required a chest tube for hemo-pneumothorax.
Another patient was diagnosed with a retropharyngeal hematoma that did not require operative intervention. One patient underwent laceration repair of the sternocleidomastoid muscle. Six additional patients were observed and did not require surgical neck exploration.
Self-inflicted stab wound sites of injury, operative interventions, and rates of therapeutic intervention. Of 11 patients with stab wounds to the chest, 5 required operative interventions and all of these were therapeutic. Injuries included myocardial, lung, and internal mammary artery lacerations. One patient required operative removal of a knife from the chest and a subsequent chest tube for hemo-pneumothorax. The remaining 6 patients did not require operative exploration and were managed either with serial chest X-rays or tube thoracostomies.
Of the 25 patients with stab wounds to the abdomen, nine underwent successful non-operative management through our admission protocol for serial exams. Of the 16 that required operative intervention, three patients were noted to have a lacerated liver that was managed non-operatively. One patient sustained a gallbladder laceration, developed bile peritonitis, and underwent a cholecystectomy.
Another individual underwent ligation of the right inferior epigastric artery. Three patients had various small and large bowel injuries resulting in resection, primary repair, or ostomy. One of these patients also required a splenectomy.
Another patient had an exploratory laparotomy, pericardial window, phrenic artery branch repair, and right ventricular laceration repair. Seven patients were found to have no acute organ injury following laparotomy.
Within 48 hours from admission, all 54 patients underwent a complete psychiatric evaluation. Contextual factors associated with their self-inflicted stab wounds as endorsed by patients are reported in Table 3. Table 4 describes the specific psychiatric diagnoses of our patient population.
In this subgroup, patient injuries included the neck 1 , chest 2 , and abdomen 5. In patient with the neck injury, superficial bilateral neck lacerations were encountered that the patient stated was related to a chain saw accident. The patient denied that his lacerations were self-inflicted, however, the patient had a history of prior suicidality and the wounds were not reflective of a chainsaw related injury.
Of the chest traumas, one individual reported that a band saw blade dislodged into his chest, however, the patient could not explain how he sustained a wrist laceration at the same time thus indicating the high likelihood for suicidality. Another patient reported that he accidentally stabbed himself in his chest. Additional information obtained from the patient's family confirmed the accident was in fact a suicide attempt.
Of the abdominal traumas, five patients reported accidental abdominal injuries including: Hitting the wrong button on a switchblade knife 1 , tripping while putting a knife away 2 , or falling on a knife 2. Such mechanisms were only fully understood and acknowledged following serial interviews conducted by the consulting psychiatric service. In the remaining two patients in which non-intentional circumstances were questioned, the first individual was intoxicated and presented with penetrating trauma to the neck.
Police later confirmed that an arrest was made in connection with the patient's injuries. The other patient was non-intoxicated and presented with a stab to the abdomen. The patient reported fixing the screw on his glasses at which time the knife slipped, puncturing his abdomen. Despite the suspicious wound and circumstances, information obtained later on supported that the injury may have been accidental.
V n Stephen was stabbed to death in an unprovoked attack nearly five months ago. Bess stabbed a slice of cucumber V n Goldstone flipped through the pages and stabbed his thumb at the paragraph he was looking for V n at n He stabbed at the omelette with his fork.
You can refer to an action of this kind as a stab in the back. See also: stab wound , stab someone in the back , stable , stabbing. Web Death.
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