Carotid artery dissection
Sanjay Gupta MD
sanjaygupta99_91 at yahoo.com
Mon Jul 2 21:03:50 BST 2007
Dear Trauma List members,
I have a difficult problem.
30 years female patient. Motor vehicle collision.
Pelvic fracture, spleen rupture, bladder rupture,
small subarachnoid bleed. Hypotensive at arrival
-underwent ex-lap, splenectomy, bladder repair. Did
well with these injuries, but remained disoriented
after extubation for a long time. One of our partners
called a neurology evaluation, who as a part of their
evaluation ordered a CT angiogram of the head which
revealed a high dissection of the left carotid artery.
The head CT is otherwise normal. Radiologist is sure
it is there. The patient moves both sides of her
bodies. The angiogram was done on the 12th day after
trauma. No obvious focal deficits - sensory or motor.
Her sensorium is gradually improving. However,
neurosurgeons and neurologists want to anticoagulate
the patient for a minimum of 3 months. I am not sure
if this will help.
Any input would be appreciated.
Thanks
Sanjay
--- "Hardcastle, Tim, Dr <tch at sun.ac.za>"
<tch at sun.ac.za> wrote:
> Jose
>
> I can't talk about level of evidence on this one -
> only personal and institutional experience, namely
> that most children who present frankly hypotensive
> for age, without adequate fluids (we try to use
> blood products early) to at least get them back to a
> reasonable baseline pressure (70+2Xage) have died,
> despite rapid assessment and rapid surgical
> intervention. We have seen a progressive tachycardia
> till the point of "no-return". The challenge with
> the small child is not the fact that they are
> hypotensive, rather the answer to whether the "are
> bleeding" or "have bled". The former group -
> permissive hypovolaemia - no problem - get them to
> definitive surgical care - still high mortality. The
> latter group - surgical intervention may do more
> harm than good; one would rather fully resus and
> investigate intensively with imaging once stable.
> The challenge is that the latter group is the vast
> majority.
>
> So in summary, it is about the decision as to
> whether surgery is the management of choice or
> rather investigae and manage SNOM, that dictates the
> need for formal resuscitation to normalish values.
> Again this is for BLUNT trauma, not penetrating
> trauma.
>
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma
> and ICU)
> ATLS instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee
> member
> Clinical Head (Director): Diana Princess of Wales
> Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
>
>
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> JOSE SUAREZ PELAEZ
> Sent: Thursday, June 14, 2007 2:33 PM
> To: Trauma & Critical Care mailing list
> Subject: Re: Pre-hospital fluid therapy.
>
>
> Dear Dr Hardcastle,
>
>
>
> Thank you for your comments.
>
>
>
> It is true that when a certain hypovelemia exists,
> increases within specific
> limits in cardiac frequency and vascular resistance
> constitute compensatory
> mechanisms for blood pressure. We also know that
> hypotension is often a late
> sign and that patients are always hemodynamically
> stable until they become
> unstable.
>
>
>
> For years our lecturers have warned about the
> existence of compensated
> shock, occult hypoperfusion and sudden
> decompensation. It is curious that
> two large retrospective studies found that
> approximately 1/3 of patients
> presented relative bradycardia and had better
> survival. This raises various
> questions.
>
>
>
> I think that no particular age avoids:
>
> 1.. Increased intravascular pressure produces
> increased uncontrolled
> bleeding and clot disruption.
> 2.. The dose-dependent damaging effects of
> isotonic fluid administration.
> What level of evidence is there in favor of
> normalizing blood pressure in
> children aged 6-8 years who present uncontrolled
> hemorrhage? What level of
> evidence is there to indicate the use of 20 ml/kg
> isotonic boluses?
> According to my review of the literature, the
> evidence is scarce.
>
>
>
> It would be a pleasure to hear your opinions on
> this.
>
>
>
>
>
> Thank you,
>
>
>
>
>
> J Suárez Peláez.
>
>
>
>
>
>
>
> ----- Original Message -----
> From: <tch at sun.ac.za>
> To: "Trauma & Critical Care mailing list"
> <trauma-list at trauma.org>
> Sent: Wednesday, June 13, 2007 4:58 PM
> Subject: RE: Pre-hospital fluid therapy.
>
>
> Jose
>
> I do have a concern about this concept in the
> younger child - under age 6-8,
> as their physiology IS different. The compensate by
> progressive tachycardia
> and maintain SBP till just too late - then drop off
> over the waterfall and
> DIE on you!
>
> For adolescents or adults I agree completely
>
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma
> and ICU)
> ATLS instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee
> member
> Clinical Head (Director): Diana Princess of Wales
> Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> JOSE SUAREZ PELAEZ
> Sent: Wednesday, June 13, 2007 5:25 PM
> To: Trauma & Critical Care mailing list
> Subject: Re: Pre-hospital fluid therapy.
>
>
> Dear Dr. Mattox,
>
>
>
> Thank you for your comments. The objective of my
> email was to hear different
> opinions from colleagues on certain issues.
>
>
>
> I believe that while SBP continues to be used as the
> main therapeutic
> objective in bleeding patients, while the
> means/devices to measure SBP are
> maintained and not replaced/complemented by other
> more sensitive measures
> (SLCO2, NIRS, etc) to detect acceptable perfusion
> indicating
> non-administration of fluids (to avoid greater
> hemorhage, re-bleeding and/or
> a systemic inflammatory response due to unnecessary
> fluid administration),
> SBP will continue to constitute the golden objective
> in pre-hospital
> treatment and set back the day when bleeding
> patients are not given
> excessive quantities of fluid that may result in
> devastating consequences,
> whether immediate or not.
>
>
>
> You and other experts have warned about the
> limitations of SBP as
> therapeutic objective and have proposed the use of
> permissive hypotension.
> However, quantities of isotonic fluids >750 ml may
> continue to be
> administered. I think the didactic use of the
> concept permissive hypovolemia
> (and not hypotension) might help to reduce excessive
> administration of
> fluids: attempting to provide each patient with only
> what he/she needs,
> specially in children.
>
>
>
> There are sufficient arguments against the need to
> normalise BP in bleeding
> patients. I think the scientific community is
> tending towards this
> viewpoint. But how to ensure the administration of
> the necessary fluid to
> achieve a balance between damage and benefit? As the
> Dutton study has shown,
> this is complicated.
>
>
>
> Perhaps, as you propose, 50 ml boluses using radial
> pulse and state of
> consciousness as endpoints, regardless of BP, could
> prevent situation like
> following: my nurse Toñi usually has BP of 70, in
> the event of an accident,
> she could be hypotensive, tachycardic, anxious, etc,
> so, she would probably
> receive excessive fluid possibly causing increased
> bleeding, re-bleeding,
> iatrogenic respiratory distress, or even multi-organ
> failure and death,
> after hemorhage control and a "normal" BP.
>
>
>
> Therefore I believe we should start to use the term
> Permissive Hypovolemia,
> not merely for semantic reasons but because of its
> conceptual and didactic
> usefulness.
>
>
>
> I would be grateful for any comments you may have
> (pro or cons)
>
>
>
>
>
> José Suarez-Peláez
>
>
>
>
>
>
> ----- Original Message-----
> From: <KMATTOX at aol.com>
> To: <trauma-list at trauma.org>
> Sent: Tuesday, June 05, 2007 12:09 PM
> Subject: Re: Pre-hospital fluid therapy.
>
>
>
> In a message dated 6/5/2007 5:27:34 A.M. Central
> Daylight Time,
> josuarez at teleline.es writes:
>
> José Suarez-Peláez
>
>
>
> Dr. Jose Suarez-Pelaez has asked this group to
> respond to an article and a
> letter to the editor in the journal, "Injury."
> The letter contains some
> germane observations and questions. Particularly,
> the question of the
> value
> of systemic blood pressure as a measure of adequacy
> of resuscitation,
> perfusion, etc. is right on. However, for the
> majority of the world,
> this readily
> available device is what is available, and Near
> Infrared Spectroscopy has
> not
> yet been standardized.
>
> I would agree that in the referenced study, the
> inclusion criteria are two
> broad and using a BP of 90/- systolic, or better
> 70/- as an entry criteria
> for
> such studies would be more appropriate.
>
> K Mattox
>
>
>
> ************************************** See what's
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Sanjay Gupta MD
Tel: 412 335 6304
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