Railway track injury

Case Report

A 30-year-old male victim of railway track injury was brought to the emergency department by police. He had a lacerated/partly avulsed wound over face, involving forehead, nose and left cheek, with traumatic evisceration of left eye [Figure 1].

Figure 1. Click to unblur
Extent of injury at the time of admission

On arrival, the patient was found to have a threatened airway in view of extensive soft tissue injury. Breathing was spontaneous with normal rate and pattern, and air entry was bilaterally equal. Hemodynamic was stable. Glasgow Coma scale score was 15/15. Rapid sequence induction was performed followed by orotracheal intubation with cricoids-pressure and manual in-line immobilization of the head and neck. He was mechanically ventilated, and fentanyl-midazolam infusion started.

Noncontrast computed tomography head and cervical spine were normal. That of face revealed multiple facial bone fractures including frontal, zygomatic and maxillary bone on left side and roof, lateral and medial wall (lamina papyracea) of left orbit. Patient was tracheostomized in view of the requirement for prolonged intubation for proper wound care and subsequent reconstructive surgeries. After few surgeries involving open reduction internal fixation of facial bones and initial stage reconstruction, his trachea was decannulated [Figure 2].

Figure 2. Click to unblur
Six months after the trauma (after several reconstructive surgeries)

He was posted for skin grafting on the raw area over left orbit. Patient was taken into operating room, multipara monitors connected, and fentanyl 120 mcg was given. Propofol 120 mg was given and before administering muscle relaxant adequacy of bag mask ventilation was checked. There appeared to be a leak somewhere as bag was not sufficiently filling. Machine, breathing circuit and mask were checked for leak but in vain. Then patient’s face was closely examined which revealed a small opening from nasal cavity communicating to outside, on the medial wall of left orbit [Figure 3]. We first tried to seal the opening using dressing pads and gauze pieces but the leak still persisted, and we were just managing to ventilate the patient with high flows of oxygen. The next plausible step was to ventilate the patient with a supraglottic airway in accordance with the difficult airway algorithm and then go for tracheal intubation after stabilizing the patient. While preparing the laryngeal mask airway, it was noted that the opening was irregular, so it was not possible to seal it from outside. We required an object that could seal the opening from the inside. Hence a nasopharyngeal airway was tried, as there was no absolute contraindication (skull base or cribriform fracture) to it knowing the previous scan of the patient nasopharyngeal airway of 8.0 mm ID was lubricated and inserted in the left nostril [Figure 4]. To our amazement, the leak was all gone! We were now able to ventilate the patient even with low flows.

Figure 3. Click to unblur
Artery clamp pointing the opening of nasal cavity through lamina papyracea
Figure 4. Click to unblur
The nasopharyngeal airway seals the rent from inside

Patient underwent 4–5 reconstructive surgeries in next few months, including skin grafting over exposed nasal mucosa. In all the surgeries, the unusual leak was kept under consideration, and a nasopharyngeal airway was used to ventilate the patient. It turned out to be an innovative use of nasopharyngeal airway to seal traumatic airway leaks from the nose.