Complication following primary repair of a penetrating bull horn injury to the trachea

A 22-year-old male patient was admitted to the casualty with a bull horn injury in the lower zone of the neck in the midline. The patient was conscious and distressed but hemodynamically stable. Local examination revealed a lacerated wound. He underwent emergency primary repair of the wound under halothane anesthesia; intubation was done keeping in readiness all preparations for difficult airway management. Postoperatively, elective controlled ventilation was performed with continuous infusion of muscle relaxant. After approximately 8 hours of controlled ventilation, the syringe pump failed; this initially went unnoticed and made the patient cough and buck on the tube. Infusion was restarted after a bolus dose of vecuronium bromide intravenously but, meanwhile, the patient developed subcutaneous emphysema in the neck. He was immediately transferred to the operating room, where exploration of the surgical site revealed dehiscence of the tracheal wound; this had led to the subcutaneous emphysema. Repair of the tracheal wound dehiscence was not possible due to both lack of space and lack of tissue for apposition. Hence, a tracheostomy tube was inserted through the tracheal wound and the patient was transferred to the intensive care unit for elective controlled ventilation. The patient was weaned off the ventilator within 24 h and transferred to the surgical ward on spontaneous ventilation with the tracheostomy tube in situ. The size of the patient's tracheostomy tube was reduced gradually by the serial exchange method. The wound ultimately healed with minimal scarring.