|Year : 2013 | Volume
| Issue : 2 | Page : 57-60
A study on behavior and management of suicidal cut throat patients
Kalpana Sharma1, Kaberi Kakati1, Subodh C Goswami1, Dipesh Bhagawati2, Manigreeva Krishnatreya3
1 Department of Otorhinolaryngology, Guwahati Medical College and Hospital, Guwahati, Assam, India
2 Department of Psychiatry, Guwahati Medical College and Hospital, Guwahati, Assam, India
3 Department of Epidemiology and Biostatistics, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
|Date of Web Publication||7-May-2014|
Department of Epidemiology and Biostatistics, Dr. B Borooah Cancer Institute, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Suicide is one of the 10 leading causes of death in the world and cut throat injuries (CTI) are fairly common due to suicide. Aims and Objective: The aim of the present study is to evaluate the pattern of injury, its management and associated psychiatric illness in suicidal CTI. Materials and Methods: A prospective study from August 2011 to April 2013 was carried out in the Department of Ear, Nose, and Throat (ENT) in collaboration with the Department of Psychiatry at Gauhati Medical College and Hospital. A total of 17 cases of suicidal CTI were included in the study irrespective of age and sex, who were admitted in the department of ENT. Results: Majority of the patients were young adults, 82.35% in the age group of 20-40 years. According to anatomical zone, 77% had injury in Zone 2 and 23% had Zone 1 injury. Hesitation injury involving skin and soft-tissues were seen in the neck in 71% of cases, and common morbidity following CTI is secondary wound infection (23.52%), persistent dysphagia (23.54%) and ugly scar (17.64%). Majority of patients (47.05%) were of acute and transient psychosis. Conclusion: Suicidal CTI is an important cause of cut neck injury in ENT practice. Proper surgical and psychiatric management of suicidal CTI plays an important role in the prevention of complications and resultant death due to CTI.
Keywords: Cut throat injury, psychiatric illness, suicidal
|How to cite this article:|
Sharma K, Kakati K, Goswami SC, Bhagawati D, Krishnatreya M. A study on behavior and management of suicidal cut throat patients. J Laryngol Voice 2013;3:57-60
| Introduction|| |
Suicide is one of the 10 leading causes of death in the world with 1 million death occurring annually.  The incidence and pattern of suicide differs from one geographic region to another because of religious, cultural, and social values which play an important part in its occurrence. Overall, 2.9% adult population attempts suicide and the suicide rate in general population in a life time period of 70 years is about 1% , and most of these individuals have an underlying psychiatric disorder. Depression (50%), alcoholism (25%), schizophrenia (10%), delirium and dementia (5%) are the common mental diseases associated with suicide. The common modes of injury are firearm, hanging, and ingestion of toxic substance. Laceration of the forearm or wrists is the most common method of self-injury, while suicidal cut throat injury (CTI) is a rare entity. Three forms of deliberate self-lacerations are found, namely (1) deep and dangerous wound done with serious suicidal intent, (2) self-mutilation by schizophrenic patients (often due to hallucinatory voice) or by transsexuals, (3) superficial wounds. Personality disorder is found in one-third to half of self-harm patients.  Family history of suicidal behavior, exposure to family violence, impulsivity, substance abuse, older age, chronic illness for a long time, loss of job, divorced, widowed, or separated are some socio-demographic risk factors in suicide. Some biologic factors like low levels of serotonin (5HT) and its major metabolites, low hydroxyl indole acetic acid (5HIAA) has been found in postmortem brains of suicide patients. Low levels of 5HIAAis found in cerebrospinal fluid of depressed people, who attempted suicide by violent methods. Alcohol and other psychoactive substance may lower level of 5HIAA.
Presence of many vital structures in the neck makes all CTI potentially life-threatening. Damage to the vital structures may become rapidly fatal from profuse hemorrhage, air embolism or airway obstruction. Injuries to the neck are divided into three anatomic zones. Zone 1 injury is between the cricoid cartilage and the clavicle, Zone 2 injury is between the cricoid cartilage and the angle of the mandible, and Zone 3 injury is between the angle of the mandible and the base of the skull. Zone 1 and Zone 3 are well protected by bones while in the Zone 2 vital structures are not protected by bone. Suicidal CTI are commonly seen in Zone 2, between the hyoid bone and the cricoid cartilage. Depending on the structures involved a patient with CTI may be asymptomatic or may present with symptoms of hoarseness, laryngeal stridor, dyspnea secondary to airway compression or aspiration of blood, external blood loss, and neck hematoma to a varying degree of shock. Exposed hypopharynx or larynx with hemorrhagic shock and asphyxia are the common cause of death following CTI. Injury to major vessels can cause death from hemorrhage, stroke or cerebral ischemia. The aim of this study is to evaluate the pattern of injury, its management and associated psychiatric illness in suicidal CTI.
| Materials and Methods|| |
This is a prospective study carried out in the Department of Ear, Nose and Throat (ENT) in consultation with Department of Psychiatry, Gauhati Medical College and Hospital. A total of 17 cases of suicidal CTI were included in the study irrespective of age and sex, who were admitted in the ENT ward from August 2011 to April 2013. Data collected were categorized according to the demographic pattern of the patients, type and site of injury (neck zone injury), presentation, underlying psychiatric illness, morbidity and mortality of the disease. Management was carried out depending on the presentation of the patients. If they presented without airway compromise, surgical repair of the wound was carried out immediately. On the other hand, establishment of an airway either via a tracheostomy or an endotracheal intubation followed by wound repair or wound debridement were done in patients presenting with respiratory distress. Use of a nasogastric tube and avoidance of oral feeding continued for 7-10 days depending on wound healing. Blood (packed cell volume, urea, and electrolyte level) examination was done to know the circulatory status. The aim of psychiatric management was to treat the underlying cause that may lead to suicide attempt. Different pharmacological agents were used after evaluations by the psychiatrists [Table 1].
|Table 1: The different psychiatric disorders as risk factor vis-à-vis pharmacological agents used for treatment of patients with suicidal CTI|
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| Results|| |
During the study period, a total number of 54 (N) CTI patients were admitted in the Department of ENT of Gauhati Medical College and hospital. Homicidal CTI was seen in 31 (57.40%) patients, suicidal CTI in 17 (31.48%), CTI due to motor vehicle accident in 3 (5.55%), gunshot injury in 2 (3.70%), and CTI due to sports injury was recorded in 1 (1.85%) patient. Out of 17 (n) suicidal CTI patients, 13 patients were males and 4 were female patients. Majority of the patients were young adults, 14 (82.35%) in the age group of 20-40 years. Fifteen patients (88.2%) were from lower socio-economic class with a rural background and two patients (11.76%) were from upper socio-economic class. The patients had either active hemorrhage (52.94%), open wound (41.17%), bandage in the neck with preliminary repair outside (35.29%) at the time of presentation. Two patients (11.76%) presented with hemorrhagic shock and severe respiratory distress [Table 2]. At the time of repair, it was observed that the majority of the patients had laryngeal injury (41.17%) followed by injury to the thyroid gland and thyroid cartilage (29.41%), pharyngeal injury (17.64%) and tracheal injury (11.76%) [Table 3]. On dividing the injury according to anatomical zone - 13 cases (76.47%) had injury in Zone 2 and 4 cases (23.52%) had Zone 1 injury. No injury was recorded in Zone 3 [Table 3]. Hesitation injury involving skin and soft-tissue were seen in the neck in 12 cases (70.58%) and three patients (17.64%) had hesitation marks in the wrists. All patients reached the hospital within 24 h of injury except one who reported after 5 days of injury. Emergency tracheostomy was done in nine patients (52.94%). Blood transfusion was required in four patients (23.52%). Hospital stay was from 10 days to 21 days. Secondary wound infection (23.52%) in four patients, persistent dysphagia (23.54%) in four patients and ugly scar (17.64%) in three patients were the common morbidities recorded in the study. Mortality rate was (11.76%) in two patients due to hemorrhagic shock.
|Table 3: Zonal distribution and structures injured of suicidal CTI patients|
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Almost all the patients used sharp household items to cause injury. The most common instrument used by the patient was kitchen knife (58.82%), razorblades (23.52%) and broken piece of glass (11.76%).
In our series of suicidal CTI, 8 (47.05%) patients were suffering from acute and transient psychosis, 6 (35.29%) patients were of major depressive disorder, 2 (11.76%) patients were of delirium following acute alcohol intoxication and 1 (5.8%) patient was of paranoid schizophrenia. In our study, two patients of suicidal CTI died during the study period. One died due to hemorrhage and hypovolemic shock and the other died due to aspiration.
| Discussion|| |
It has been observed that suicidal CTI is rare in India.  There is reported incidence of 10.45% suicidal CTI.  In our study, the incidence of suicidal CTI is alarmingly high with as high as 31.48% of all CTI. Appropriate measures can save lives in the vast majority of patients with CTI. If CTI's are left untreated or improperly managed, patient may develop secondary wound infection, late tracheal stenosis or pharyngocutaneous fistula as sequelae. In our study, dysphagia and hoarseness were seen as common post injury sequelae in suicidal CTI. Immediate resuscitation by securing an airway with the help of tracheostomy or intubation, prompt control of external hemorrhage and blood transfusion in case of circulatory collapse and repair of the cut wound is indicated in the surgical management of these patients. In this study, majority of patients (59%) presented with active bleeding from injury and in 50% of patients tracheostomy was required. The early management of mental health involves medical stabilization, along with a supportive attitude by the medical staff and family members. In our study, majority of patients (48%) had acute and transient psychosis. A small minority (6%) of patients require antidepressant drugs due to their depression. All patients require hospitalization. There is a possibility of the second attempt of suicide in some patients and thus the need of psychological support may linger long after the neck wound have healed. , High incidence of suicidal CTI in young male represents a significant public health problem. Studies on suicidal CTI are few and as a result the incidence of associated psychiatric illness, morbidity and mortality arising from this spectrum of disease is largely unknown. Reports of suicidal CTI are few in the medical literature.
In the present study, majority of the patients were young male with underlying psychiatric illness. Review of literature shows suicidal injuries are common in male than female.  Mental illness associated with suicide may be schizophrenia, anxiety disorder, posttraumatic stress disorder, delirium, dementia, and substance abuse. A positive family history is also regarded as a precipitating factor. More violent and deeper cut injuries were noticed in patients of psychosis and schizophrenia. Hesitation marks were more pronounced in patients of depressive disorders. Transient psychosis and delirium usually have an acute onset following acute stress and most of them recover within a month. Major depressive disorder and schizophrenia usually have a longer history with poor chance of complete recovery. They require psychological support for a longer time.
It is reported that about one-third who attempt suicide will repeat the attempt within 1 year and about 10% of those who threaten or attempts suicide eventually do kill themselves.  Review of the literature shows that knife is commonly used (62%) and razorblade is used by 15% in suicidal cut throat patients.  In our series of patients, kitchen knife was the commonest instrument used followed by razor blades and broken piece of glass. One patient who was suffering from paranoid schizophrenia had used hacksaw blade as the instrument for suicidal CTI.
Adequate wound toileting and a meticulous repair of the wound is always necessary for better healing. In our study, there was mortality in 11% of patients, with 50% of deaths occuring either due to hypovolemia or aspiration pneumonitis. Long-term follow-up of patients with suicidal CTI is required to detect morbidity, other than sequelae to soft-tissue injury of the neck or underlying structures in the throat.
| Conclusion|| |
Suicidal CTI is an important cause of cut neck or throat injury in ENT practice. Proper surgical and psychiatric management of suicidal CTI plays an important role in the prevention of complication and resultant death due to CTI. Management of these patients requires a collaborative approach of Otolaryngologist, Psychiatrist as well Anesthesiologists.
| Acknowledgment|| |
The authors would like to thank Dr. K C Saikia, Principal of Guwahati Medical College and Hospital for his encouragement and support in carrying out the study.
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[Table 1], [Table 2], [Table 3]