- The patient suffered a penetrating injury from a sharp log of wood that pierced his floor of mouth and exited through his neck. - He underwent damage control surgery under monitored anesthesia care to remove the foreign body and repair the wound. - The surgery involved stabilizing the patient's neck, cutting the log to a manageable size, securing his airway, removing the wood, and closing the wound primarily. - He later required maxillofacial surgery under general anesthesia for further treatment, which was completed successfully.

1. A case of penetrating injury to floor of
mouth posted for damage control surgery
Dr. Ramkrishna Bhue
2nd year pg
Dept of anaesthesia
MKCG MCH

2. Case Scenario
• Date- 10.02.17
• Time- 9:15 AM
• Place – ENT OT
• Emergency call for Damage control surgery Under
Anesthesia for a penetrating injury of floor of
mouth

3. At ENT OT
• Time – 10:20 PM
• ON 1st sight of patient
• Pt. – Bhabit Patra,26year HM, s/o – Subha Patra
at Jharipanai, P.S. - Belagarh
• on wheel chair
• Concious, responding,
• Breathing quietly
• One patent IV line on DNS @ 10 drop/min
• HR 76, BP 124/72

4. ON FIRST SIGHT

6. Brief History
• According to the relative
• The pat fall from a height 10 m under construction
bridge on 09 feb while returning to home in bike
• A sharp log of wood pierce below mandible and exit
through hind neck
• At spot his was unconscious taken to nearest CHC
where the log was cut to length of 1 m from 4
meters, given primary medication and referred to
our institute around 3:30 AM 10 FEB

7. • n/h/o- DM,HTN, Seizure, asthma
• n/k/c- TB, SCD
• p/h- of occasional alcohol and tobacco consumption
• O/E-

8. IN LINE STABILISATION
• Restrict movement of neck
• Suport to head to avoid torsion
• Cutting the wood both ends with electric saw tooth
from 1m to 30 cm
• Any head injuries , spine injuries, blunt trauma was
rule out by inspection
• CTVS consultation for rule out any large vessels
involvement

9. Initial plan of management
• Proposal for Tracheostomy
• Emergency airway secure equipments were ready
• Then to do a in line stbilisation was necessary
• The log was cur to 30cm with a motor sawtooth for
facilitate

10. Wood been cut

11. Airway, breathing & circulation
• All emergency airway kitt was ready
• ET tubes , Magils, suction, boogie
• Emergency tracheotomy if needed
• Chest was clear
• Adequate chest rise during respiration
• 2 patent peripheral IV line 20 g and 18g was
established, also central venous Catheter was in
hand, 1 Rl and 1NS started rapidly

12. Forign body Removal & clousre
• Under Monitered Anaesthesia
• 12:30 PM
• Premedication
• Inj gyco 0.2 mg I.V.
• Inj midaz 1.5 mg I.V.
• Inj fortwin 15mg I.V.
• Inj dexemeditomidine 100mic in 500ml N.S. @ 30dpm
• Oxygenation – with nasal canula @ 6lpm
• Inj ketamine 10mg IV when manual handling and removal
of wood if required

13. Primary closure

14. Vitals during Monitor Anesthesia care
• PR:- 80- 120/ MIN
• NIBP:- 110-130/ 70-80 mm Hg
• Spo2:- 85-100%
• Oxygenation :- @ 6LPM thorgh nasal probe
• IVF- RL – NS- RL – DNS

15. Monitor Anesthesia care

16. • Pt was deeply sedated
• As soon as wood was pulled out thorough oral
cavity inspection and suction was done DL
• Laryngeal reflex was intact
• Monitor anesthesia was continued till primary
closure of wound repair
• After arrival of Maxo- facial surgeon , nasal
intubation was planned at 3.00 PM

17. Maxilo- Facial const. Under GA
• 03:30 PM
• Premed – inj glyco 0.2mg IV
• Induction- inj Ketamine 40 mg iv + propfol 60mg IV
• Intubation – inj scholine 100mg iv
• Nasal intubation was succesful in 2nd attempt
• After b/l ascultation the flexometallic Ettube of size
7.0 was fixed
• Maintainanace - N2O :O2= 3:2
• Isoflurane – 1%

19. • Once scholine affect gone
• Inj vec. 5mg IV
• Mechanical Ventilation- volume control mode
• TV – 500 ml
• PEEP – 3
• I:E – 1:2

21. INTRA OP
• PR - 90- 120
• NIBP- 90 -130/ 65- 85 mmHg
• Spo2 – 92- 100%
• INJ Vec. – 1 mg + 1mg 1mg
• IVF- 1 NS
• Intermittent oral suction was done
• After Adequate respiratory effort MV was changed
to BAG & Mask ventilation with hypovenilation
• Isoflurane was stopped

23. 4: 50 pm
• REVERSAL
• Inj glyco 0.5mg + Neostigmine 2.5 mg IV
• RECOVEY
• Spontaneous eye opening
• Obeys command
• EXTUBATION
• Oral suction , ET Tube was decuffed and put on Mask
Ventilation
• Pt was under observation 20 mins

24. POST OP
• pt consious oriented
• PR 96
• BP 118/76 mm Hg
• Spo2 – 97% in room air
• ADVISE
• O2 @ 4l/min for 8 hours, prop up postion
• NPO – 12 hours , IV fliuds
• Analgesis if reqiured
• Call SOS

25. Day 2 post op

26. TEAM ENT
• ASSO. PROF. DR. SHREE NANDA
• ASSO.PROF. DR. SANJEEV PATRO
• DR DURGADATT
• DR KARUNAKR
• DR RAMKRISHNA
• SPECIAL THANKS TO
• PROF. DR L.D. DASH
• ASSO. PROF . DR D.N. SHARMA