A novel technique of anesthesia induction in supine position with impaled knife in the back.

Current technique of airway management for impaled knife in the back includes putting the patient in lateral position and intubation. We present here a novel technique of anesthesia induction (intubation and central line insertion) in a patient with impaled knife in the back which is simple and easily reproducible. This technique can be used for single lung ventilation using double lumen tube or bronchial blocker also if desired.

INTRODUCTION

Impaled knife in the back is often an anesthetic challenge as patient cannot be put on supine position. Current technique of airway management includes putting the patient in lateral position and intubation.[123] We present here a novel technique of anesthesia induction in a patient with impaled knife in the back.

CASE HISTORY

The Patient

A 35-year-old male presented with a knife in the back [Figure 1]. Computerized tomography of the chest was performed in the prone position [Figure 2] which revealed knife inside the right chest with partial collapse of the lung and right hemopneumothorax.

Figure 1

Picture of the patient and chest X-ray taken bedside

Figure 2

Computerized tomography chest performed in the prone position

The patient was taken to the head end of the operating table and was put on lateral position with the upper part of the body supported by a surgical trolley. Height of the operating table was adjusted to the level of the surgical trolley. Now the patient was put on supine position - the lower part of the body was at the head end of the operating table and the part of the torso above the knife impalement site was supported by a surgical trolley. The gap in between the head end of the table and the surgical trolley accommodated the impaled knife [Figures 3 and 4]. Chest tube was inserted before anesthesia induction under local anesthesia because of hemopneumothorax. Anesthesia induction, intubation was performed following conventional technique in this position. Central venous access through right internal jugular vein was secured in the same position. After intubation and central venous access, patient was made lateral for right posterolateral thoracotomy and moved towards the foot end of the operating table [Figure 5] so that surgical trolley was removed and upper body was also on the operating table. Surgical plan was to perform a thoracotomy before removing the knife so that hemorrhage from injury can be controlled easily.

Figure 3

Patient position for anesthesia: Patient is taken to the head end of the table, and the part of the torso above the knife impalement site is supported by a surgical trolley. The gap in between the head end of the table and the surgical trolley accommodated the impaled knife

Figure 4

Different view of the patient position for anesthesia induction. Internal jugular line was inserted in this position

Figure 5

Position of the patient for thoracotomy and incision

Right posterolateral thoracotomy was performed, and the impaled knife was removed [Figure 5]. There was profuse bleeding from intercostal artery which was controlled and the patient required middle and lower lobectomy. This operation was performed at 2 a.m. and double lumen tube or bronchial blocker was not available. We decided that the risk of waiting will be more as patient had developed hemothorax. As the injury was very close to the hylum, it was decided that middle and lower lobectomy will be a safer option than trying to repair the lung tear. Rest of the operation was completed in conventional manner.

DISCUSSION

Impaled knife in the back is an anesthetic challenge as the patient cannot be put on supine position. Various techniques of intubation in the lateral position of single lumen or double lumen tube have been described.[123] Intubation in the lateral position is often difficult in the trauma patient because of unfamiliar position and a full stomach.

The technique described by us is simple. It involves using a surgical trolley (which is universally available) to support the head and upper torso and keeping a gap between the trolley and the head end of the table to accommodate the impaled knife. After the patient had been put in the supine position, the anesthesia induction procedure was routine. We decided not to use double lumen tube. However, double lumen tube can be easily used in this novel technique. For thoracotomy, patient was made lateral and then moved toward the foot end of the table. After an extensive search of the literature, we could not find any report of this technique.

One limitation of this technique must be recognized - the height of the operating table has to be adjusted as the height of the surgical trolley available was fixed. But we feel that intubation and insertion of the neck line in the supine position is easier because of the familiar anatomy. We recommend routine use of this induction positioning in patients with impaled knife in the back.

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.