We are following news reports that the alleged Boston bomber Dzhokar Tsarnaev is currently intubated (breathing tube placed) and sedated, as we surmised earlier would be the case, with injuries to the “throat.”
This is a medically imprecise description that would not be used by a trauma surgeon and in civilian parlance can mean one of several things. Likely it is an indication that he was injured by a gunshot wound to his trachea or esophagus. These are wounds that are not as immediately life-threatening as a gunshot wound to the carotid artery but can cause a longer and more difficult recovery.
A gunshot wound to the trachea with a high caliber bullet would likely cause significant cartilage damage that will require extensive reconstruction by otolaryngologists and likely caused the placement of a tracheostomy. What is a key fact to be discerned is whether there was an injury to his larynx (voicebox) and if so, what the extent of the damage might be.
Reconstructing a trachea without underlying damage to the voice structures is something well within the capabilities of the ENT staff at Beth Israel Deaconess Medical Center, as is reconstruction of the larynx if the damage is not too extensive. In the setting of complete destruction of the voice structures, artificial speaking devices can be used to produce simulated speech. Any reconstruction would be done at a later surgery date with the patient kept intubated and sedated until that time.
Even in the setting of no injury to the voice structures, generally tracheostomy tubes are downsized over several days when the patient is weaned and taken off the ventilator. It is possible to put a one-way valve on the trach so that specch can be accomplished, but this is typically many days after the placement of the trach itself.
The most ominous injury that is not immediately life-threatening but can cause significant mortality would be a gunshot wound to the esophagus that involved the intrathoracic part of the goose. Injury here left unattended for more than 20 hours would likely cause significant mediastinitis and might require a thoracotomy (chest incision) or thorascopy to adequately drain the mediastinum (area between the lungs and around the heart and aorta and vena cava.) Chest tubes bilaterally would be left to effect continued drainage to try to dampen down the infection in the tissues.
If the injury was to the cervical esophagus (in the neck only), the chance for mediastinitis is less and the manangement somewhat easier, but in both injuries likely the esophagus would be kept in discontinuation with the formation of a spit fistula or placement of nasogastric tubes to control saliva secretion. Injuries to the esophagus would require days to weeks of ICU care and a prolonged intubation course.
The patient is likely being sedated with fentanyl and midazolam continuous infusion or some combination of narcotic drip and a benzodiazepine.
While a “throat wound” with a military style rifle is very serious the level of care and experience required to recover this patient would be well within the abilities of the surgical and nursing staffs at Beth Israel Deaconess Medical Center. The patient is likely not even the “sickest” patient in the surgical or trauma unit right now at BIDMC.
One key question would be to determine if the patient was on any vasopressors or inotropic drugs to keep his blood pressure high enough to perfuse his internal organs. Likely he is not currently on any pressors as he is not listed in critical condition.
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