Presentation
Psychiatric patient, self-inflicted neck wounds.
Patient Data
Well placed ETT.
Dislodged tooth in oropharynx behind the ETT.
Wide skin laceration anterior to the larynx, with subcutaneous emphysema tracking along several cervical planes.
Puncture wounds on both sides of right internal jugular vein wall at the level of the skin laceration. No evidence of internal bleed.
Intraoperative photo: tying off the right internal jugular vein.
Case Discussion
A high-functioning psychiatric patient attempted suicide by taking scissors to his own throat after having been off his first-line medication for a couple of weeks. He had a large deep skin laceration (7 x 4 cm) in the center of the anterior neck, plus several small incisions around it. No active bleeding seen on arrival to the ER. A steep drop in hemoglobin from the patient's baseline was appreciated. According to the patient's wife, he had bled profusely through the large wound.
At CT, there was no evidence of internal bleed. The most notable finding, albeit subtle, was a focal trauma (puncture) to the opposing walls of the right internal jugular vein (RIJV), interpreted as a puncture wound through one wall and out the other. This was verified at surgery, where, on opening the carotid sheath, the RIJV was seen to bleed actively through puncture wounds in its anterior and posterior walls. The internal and external right jugular veins were tied off (see photo).