Postępowanie anestezjologiczne w ranie postrzałowej szyi. Opis przypadku

Waldemar Machała

Summary
Background. Gunshot wounds of the neck are often associated with oral and intrathoracic injuries. These injuries may initially be occult, but will demand attention. Wounds caused by P-64 pistol, 9 mm full metal-jacket bullets with lead core and initial speed lower than 600 m s^-1 are classified low-velocity gunshot wounds where the bullets do not deform significantly in tissue, but penetrate deeply. Case report. A 24-yr-old man was admitted in a satisfactory general condition to the hospital after being shot by a policeman. The inlet wound was found above the sternal notch; the outlet – on the back in the 7^th intercostal space, and subcutaneous emphysema was present in surrounding tissues. A thoracic drain was inserted and the patient transferred to the operating theatre. A thoracic epidural catheter was inserted via Th₄-Th₅ interspace and 0.1 mg fentanyl and 30 mg ketamine was given. General anaesthesia was induced with fentanyl and midazolam, and the patient intubated with a double lumen tube. The bullet, after entering the body, probably changed its direction because of rotation and deflection caused by the sternum. Emergency thoracotomy was performed, revealing limited damage to the upper left lobe. The lung was cleaned and sutured and the chest wall was closed. The patient was extubated within one hour after surgery and made a good recovery. Conclusions. One lung ventilation and anaesthesia with a thoracic epidural appeared to be an appropriate technique for the described type of surgery. Since the effect of a gunshot neck wound is unpredictable, special caution is required during preparation and anaesthesia.

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