Weaning difficulty in a near hanging patient: An unusual cause.

Suicidal hanging causes damage to the airways, neck blood vessels as well as soft tissue injuries. We report the development of tracheo-esophageal fistula in such a patient. Recurrent soiling of the airways and the resultant lung infection led to weaning failure. We highlight the approach to diagnosis and appropriate management in such a patient.

INTRODUCTION

Hanging is a common mode of committing suicide. Such patients normally suffer damage to the airways and blood vessels. Damage to the aerodigestive tracts has not been commonly reported.

CASE REPORT

A 10-year-old male patient was admitted shortly after his parents discovered him hanging (around 2–3 min) from the shower. He was brought to the emergency room within 2 h in an unconscious state (Glassgow Coma Scale was 3). There was ligature mark on the neck without any signs of soft tissue injury. He was promptly intubated in the emergency department in view of severe hypoxemia and unconscious state. He was intubated by rapid sequence intubation by a trained emergency physician who introduced a 6.0 mm sized endotracheal tube under direct vision through the vocal cords and the position confirmed by an EtCO2 meter. The periprocedural period was uneventful. He was managed with ventilator support, antibiotics, and intravenous fluids. His consciousness improved within 24 h and he was put on pressure support ventilation. All the parameters of the patient improved steadily. He however developed bloody Ryle's tube aspirate for which pantoprazole infusion was started (for possible erosive gastritis). In the next 24 h, ventilator support was reduced and extubation was planned. However, he developed new onset fever with tachypnea and oxygen requirement accompanied by leukocytosis and newly developing infiltrates [Figure 1]. Controlled ventilation was re-initiated and antibiotics were upgraded for the developing ventilator associated pneumonia. The patient improved and weaning was re-started, but after 2 days, he again developed fresh infiltrates and fever. As Ryle's tube aspirate remained bloody an upper gastrointestinal endoscopy (UGIE) and computed tomography (CT) scan of thorax and abdomen was ordered. UGIE showed an ulcer in anterior wall of esophagus with mild oozing [Figure 2]. CT thorax showed pneumomediastinum with consolidation in both lung fields (right > left) [Figure 3]. In view of recurrent pneumonitic changes, presence of bloody aspirate from Ryles's tube, and pneumomediastinum an aberrant connection between airway and the digestive tract was suspected. A contrast-enhanced CT thorax was planned with injection of the contrast through a Ryle's tube which was withdrawn to the level of the upper esophagus [Figure 4]. Contrast leak was seen at the level of C7 indicating a tracheoesophageal fistula. The patient's enteral feeding was stopped and he was put on continuous Ryle's tube aspiration and parenteral nutrition. Within 4 days, the patient was successfully weaned from the ventilator. Subsequently, repeat contrast CT studies showed no leak from the esophagus indicating healing of the fistulous tract. Oral feeding was started which the patient was able to tolerate. This case, thus, describes the development of tracheoesophageal fistula in a near-hanging patient which has not been reported previously in literature to the best of our knowledge.

Figure 1

X-ray of the patient showing widespread infiltrates (right > left)

Figure 2

Upper gastrointestinal endoscopy showing ulcers near the site of fistulous connection in the anterior part of esophagus

Figure 3

Computed tomography thorax showing the presence of pneumonitic changes (right > left)

Figure 4

A thin rim of air is seen around the trachea due to pneumo-mediastinum

Hanging is a common method of suicide particularly in young adults[1] and in India hanging accounts for around 25% of all suicidal attempts.[2] Near hanging refer to those cases where a patient survives hanging injury long enough to reach a medical care facility. In judicial hanging, the cause of death is usually fracture or dislocation of cervical vertebra and vasovagal shock.[3] In suicidal hanging, the cause of death is compression of airway and blood vessels causing hypoxia and cerebral ischemia.[4] Pulmonary distress is a common consequence of hanging and is thought to be an independent predictor of mortality.[5] The common causes thought are negative pressure pulmonary edema and acute respiratory distress syndrome.[5]

Tracheo-esophageal fistula (TOF) refers to the abnormal communication between the trachea and the esophagus which may be either congenital or acquired. The acquired causes are malignancy, trauma, infections, surgery, etc.[6] Traumatic TOF follows either blunt trauma or open avulsion injury to neck or thorax. Strangulation has been reported to cause tracheobronchial injury with transection.[7] However, hanging causing tracheobronchial injury and formation of TOF has never been reported previously. In this case, near hanging resulted in development of TOF. The mechanism of injury can be postulated as – forceful expiration against a closed glottis or closed airway (due to the tight rope around the neck) which lead to an “explosive” injury to the trachea and the esophagus as suggested by Kirsh et al.[8] In a ventilated patient who has unexplained weight loss, recurrent chest infections and failure to wean the presence of a TOF is to be suspected and actively sought for.[9] In such cases, persistent tracheal soiling results in increased trachea bronchial secretion on suctioning of and pneumonia. Diagnosis includes initial chest imaging which can demonstrate indirect features suggesting aero-digestive tract injury such as pneumothorax or pneumomediastinum. CT done after instillation of dye in the esophagus canreveal the abnormal communication. Endoscopy in the form of esophagoscopy or bronchoscopy can reveal the site of fistulous communication. The treatment of TOF mainly banks on surgical repair which should be ideally being performed early. Nonoperative management carries a mortality rate of 80%.[10] However, in ventilated patients, the management entails stabilization of the patient and supportive treatment till the patient can be weaned from the ventilator. The reason being after corrective surgery, postoperative pressure ventilation has shown to increase the risk of anastomotic dehiscences and leak. In ventilated patients, the cuff of the endotracheal ortracheal tube should be kept distal to the site of fistula. The bed end should be elevated to decrease regurgitation and aggressive pulmonary toileting should be practiced.[11]

This case brings forward certain noteworthy features. Injury to the neck due to hanging can cause TOF - an association which has not been described previously. The case highlights the necessity of having a high index of suspicion in the cases of ventilated patients having recurrent weaning failures and chest infections. The treatment differs in ventilated patients vis-à-vis nonventilated patients. In ventilated patients supportive treatment aimed at reducing tracheal soiling and treatment of infection is imperative followed by timely extubation.[12] Definitive surgical repair is to be carried on after weaning from ventilator.

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