Attempted Suicide by Cutthroat Laceration and Medication Overdose: A Case Report and Review of Current Literature

Benjamin Kennedy^1*, Varun Sama¹ and Milad Behbahaninia^2
*Correspondence: Benjamin Kennedy, Department of General Surgery, University of South Florida, USA, Tel: +1 8033516411, Email:

Keywords

Neck trauma • Penetration injury • Cutthroat • Overdose • Suicide

Introduction

Suicide rates continue to rise in the United States, with the majority increase being males with firearms [1]. Drug-related suicides continue to rise as well, with overall drug overdose mortality increasing fivefold in the last 2 decades [2]. Around 1.8% of trauma admissions are related to suicide attempts, with 30% of these occurring in the head and neck region [3,4]. Self-inflicted cutthroat lacerations are a rare trauma mechanism [5]. The management of these injuries, especially in zone II of the neck can be challenging [6]. Timely identification and management of injuries in this zone are critical in limiting morbidity and mortality. Furthermore, concomitant drug overdose management may be necessary in the acute post-trauma setting [7,8]. Toxicology is less familiar to trauma surgeons and cannot be neglected when providing critical care (Figure 1).

Case Presentation

Trauma bay

A 50-year-old male with a past medical history of anxiety and panic attacks presented as a trauma activation after attempting suicide by knife. Patient just prior to attempt ingested 30 tablets of 100 mg trazodone and 8 tablets clonazepam 2.5 mg. The patient first cut his right wrist transversely approximately 4 cm and then proceeded with cutting his anterior neck approximately 22 cm in length. Patient was transported via ambulance to the trauma bay. Patient arrived normotensive, non-tachycardic, saturating 99% on room air and GCS of 15. Patient was noted to have venous hemorrhage, but no active arterial pulsatile bleeding at that time. Patient’s airway was secured with endotracheal intubation and patient was taken emergently to the operating room for exploration.

Operating room

In the operating room the patient was placed in the supine position. The laceration was noted to be from ear to ear at the level of the thyroid cartilage, measuring at least 22 cm in length. There was violation of the platysma along the entire laceration with exposed muscle. The wound was explored for major bleeding vessels; one small unnamed arterial branch was ligated on the right lateral side of the laceration. There were bleeding veins throughout the entire wound that were controlled with electrocautery. Next, excisional debridement was performed of non-viable skin, subcutaneous fat, fascia and muscle. The wound was then irrigated. For closure, the 22 cm incision was closed in multiple layers. The platysma was closed first with absorbable suture. A penrose drain was then placed superficial to the platysma. The dermis and skin were then closed with absorbable suture.

To evaluate the esophagus, an upper endoscopy was performed in the operating room. The gastroscope was introduced into the esophagus under direct visualization. The stomach mucosa was examined thoroughly including retroflexion, no additional pathology was found. There were no remnants of any undigested food or medications. The gastroscope was then slowly retracted into the esophagus and the mucosa was examined circumferentially while retracting the scope. No other pathology was seen. To evaluate the trachea, a bronchoscopy was performed in the operating room. The bronchoscope was advanced to the carina and then further into the right main and left main bronchi, no other pathology identified. The endotracheal tube was then retracted several centimeters to allow circumferential examination of the superior trachea. No further injuries identified and the endotracheal tube was advanced back to the correct position. This concluded the end of the case.

Postoperative course

Patient was admitted to the Surgical Trauma Intensive Care Unit (STICU) immediately postop for ventilatory management and continuous telemetry monitoring. Patient was given activated charcoal with polyethylene glycol for his overdose on trazodone and clonazepam. Patient in the first 12 hours best Glasgow Coma Scale Score was 10 with intermittent periods of apnea. Patient’s sedation and analgesia were paused at that time. Patient remained intubated on postoperative day 1 until 18 hours postop due to continued periods of apnea while on pressure support. Postoperative day 2 patient was extubated on room air and tolerating a regular diet without dysphagia. Postoperative day 3 patient as transferred to the floor. Postoperative day 5, patient was evaluated by the psychiatry team and the clonazepam taper was completed. The penrose drain was also removed on this day. Postoperative day 6, patient was started on olanzapine. Postoperative day 7 patient was discharged home. Patient was seen in clinic 2 months postop, noted to be doing well, with a well-healed incision with no active issues. A referral was placed to plastic surgery for elective scar revision.

Discussion

Suicide rates continue to rise in the United States. Self-inflicted injury by firearm remains the most common mechanism of penetrating trauma in suicide, contributing to over half of all deaths, with a growth rate that trails only slightly behind overall suicide increases. In contrast, death from self-inflicted injuries by sharp object are far less common but have grown disproportionately rapidly over the past two decades, at more than double the rate of overall suicide deaths [1,2]. Age-adjusted suicide mortality from all mechanisms rose from 10.71 to 14.03 per 100,000 people between 2001 and 2021, a 31% increase. Suicide by firearm rose 27% in the same period, from 5.9 to 7.5 per 100,000, while cutting/piercing increased by 69%, from 0.16 to 0.27 per 100,000.8 Rates of suicide by primary drug overdose have risen more modestly, with crude mortality increasing from 1.2 to 1.3 per 100,000 between 2001 and 2021 [1]. By contrast, age-adjusted mortality for overall drug overdose increased fivefold in that time, from 6.8 to 32.4 per 100,000 [2]. Penetrating neck injuries carry a higher level of morbidity and mortality due to the density of vital structures with lack of musculoskeletal protection. The neck region was classically divided into 3 anatomic zones. Zone I from the clavicles and sternal notch to the cricoid cartilage. Zone II between the cricoid cartilage and the angel of the mandible. Zone III from the angle of the mandible to the base of the skull. The zones were described to be used to try and predict what structures were at risk of injury. Zone I includes the large vascular structures of the superior mediastinum, the innominate and subclavian vessels, internal jugular veins, carotid arteries, esophagus and trachea. Zone II includes the carotid arteries, the vertebral arteries, internal jugular veins, trachea and esophagus. Zone II is most accessible for the trauma surgeon to intervene on. Zone III includes distal carotid arteries, jugular veins, distal vertebral arteries and the oropharynx. Of note, Zone III injuries are anatomically challenging for surgeons to reach and are therefore not typically explored open [9]. This patient presented with a Zone II injury with bleeding and violation of the platysma along the entire 22 cm incision. It was crucial to rule out injuries to the aerodigestive tract and major vessels. In penetrating neck trauma cases the incidence of vascular injury is up to 25% and aerodigestive tract injury up to 30% [9]. As this patient had active bleeding, they were taken to the operating room emergently for exploration and were further assessed with bronchoscopy and upper endoscopy. This case was further complicated by home-medication overdose. Self-inflicted lacerations to the neck are managed through the ATLS algorithm, with workup and operative exploration as indicated. Concomitant drug overdose, as in this case, is a complicating factor of patient care in the perioperative trauma bay and STICU settings. One analysis of the CDC’s National Violent Death Reporting System (NVDRS), which includes toxicology, coroner and law enforcement reports, showed that prescription or illicit drugs were present in 22% of firearm suicides, most often benzodiazepines and opioids [7]. These findings highlight that drug ingestion is frequently present even when overdose is not the primary mechanism of suicide, although inconsistent practices of toxicology testing likely underestimates prevalence and misrepresents distribution of each specific drug class. Suicide by drug intoxication alone is likely profoundly under-reported in cases in absence of a suicide note, previous attempt, or depression history, especially in comparison to suicide by firearms and hanging [10].

Combined, these findings suggest that non-poisoning suicide methods, in our case penetrating self-inflicted cutthroat laceration, can potentially obscure drug presence or concurrent overdose. For this reason, diligence on the part of the trauma surgeon and accompanying team to the toxicological status and potential complications in their patients is warranted in the perioperative management of self-inflicted penetrating trauma. For the case discussed in this report, presentation of the patient’s self-inflicted neck injury was concomitant with ingestion of 30 tablets of 100 mg trazodone and 8 2.5 mg clonazepam tablets prior to suicide attempt via laceration. The total 3-gram dosage of trazodone is well above the maximum FDA-approved label of 600 mg for inpatient major depression and is also the most frequent dose associated with emergency department treatment and discharge in the United States [11]. It further exceeds the median dose of 1.5 g associated with ICU admission for major effects such as Central Nervous System (CNS) depression, cardiac arrhythmia and hypotension [12]. Although isolated overdose of benzodiazepines such as clonazepam is rarely associated with mortality, they are frequently co-ingested with other central nervous system depressants such as alcohol, opioids and in this case, antidepressants like trazodone [13]. The combination of trazodone and clonazepam in this patient is clinically significant in the context of trauma surgical management because of their synergistic CNS and respiratory depressant effects. For this reason, airway protection and postoperative ventilatory management are of particular importance in patients with suspected sedative co-ingestion. In this case, the patient required mechanical ventilation for approximately 18 hours postoperatively due to recurrent apneic episodes on pressure support, consistent with delayed recovery from combined drug intoxication.

In the context of the patient’s overall management, airway protection was prioritized immediately, consistent with the Advanced Trauma Life Support (ATLS) principles for traumatic neck injury as well as standard practice in cases of drug-related respiratory depression [14]. After surgical exploration and repair, further toxicological management was undertaken in the STICU with activated charcoal to adsorb ingested drug and whole bowel irrigation with Polyethylene Glycol (PEG) to enhance gastrointestinal clearance of unabsorbed drug, both established decontamination strategies in large ingestions once the airway is secured [15,16]. These interventions, combined with close ventilatory monitoring at the ICU level, aimed to limit further absorption of the ingested drugs and mitigate delayed toxicologic manifestations of respiratory and CNS depression. These toxicology interventions are not common practices in the trauma surgeon’s world, but are significant when providing comprehensive critical care. To place this case in broader context, Table 1 below summarizes common drug classes implicated in suicidal overdose, their characteristic toxidromes and management strategies relevant to trauma and ICU care, adapted from prior epidemiological analyses [17,18].

Table 1.  Common drug classes implicated in suicidal overdose, their characteristic toxidromes and management strategies relevant to trauma and ICU care [17,18].

Conclusion

Self-inflicted cutthroat lacerations are a rare form of penetrating neck trauma. These mechanisms have an elevated level of morbidity and mortality. Prompt operative investigation of associated injured structures is crucial for patient outcomes. These patients are further complicated by ingestion of toxic levels of medications and recreational drugs, for which the trauma team must be knowledgeable in treating.

Acknowledgement

None

Conflict of Interest

None

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