BEST CASE OF MY CAREER

[sjasmd at aol.com]

Ken
your points are all good. When I first arrived he was intubated and fighting the ventilator and seemed to calm down when i instructed him to relax and let the blower breath for him. He was moving all his extremities. Perhaps his agitation had to do with severe anemia and cerebral insufficiency but I dont think he had any focal signs upon my arrival. After that we sedated him with atavan.

The angiogram whose lateral view was the only one that you saw? revealed an occluded internal carotid artery and a fairly high injury of the external carotid artery. Given the location of the external carotid injury, i presumed that the injury of the ICA was also fairly high and that the more proximal occlusion merely represented clot that had propogated down. There were also two ECA branches that were bleeding, but not visualized without selective catheterization of the occipital and the posterior auricular branches.

By the way, good pickup on the collateral flow to the ophthalmic from the internal maxillary artery.

As is standard practice, any injury of the carotid or vertebral arteries found by angiography warrants full angiography of both carotids and both vertebral arteries. The left vertebral arteriogram (attached) showed prominent collateral flow from the vertebral through the posterior communicating artery. The right carotid and vertebral arteriograms did not show flow to the distribution of the left internal carotid artery.

OK, so you would like the internal carotid artery embolized. The question that comes up is should the occluded vessel be secured with some coils proximally. Or would you like me to advance the catheter through the clot in the hopes that I can get into the distal ICA and do embolization there first.

Hold on to your ideas about what to do without an intact Circle of Willis for the moment. Lets get back to that strategy later.


sal


-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Sun, 29 Jun 2008 12:23 pm
Subject: Re: BEST CASE OF MY CAREER



First, Sal thanks for the Case for us to review.   I was on duty  as well 
yesterday and also had a CAROTID injury, but we went directly from the  
ambulance 
dock to the OR and did not have benefit of an angiogram.  
 
In your case:   We have basically ONE  view.     I cannot make out the 
"balloon" or what it  occludes.    You have asked for opinions as to "What to do  

NEXT?"     I see NO intracerebral circulation, but I think I  see ophthalmic 
vessels from the left external carotid circulation.    We do not have any 
description of the status of the patient now that left  external carotid is 
occluded. 
    If the patient is viable,  I would request of YOU, now that you are in 
the arteriogram suite to inject the  RIGHT carotid artery and look at the cross 
circulation.    If the  patient is CNS intact, and there is CROSS circulation 
with an intact circle of  Willis, I would ask you then totally occlude the 
Left Internal  Carotid.    I would like to know what your LEFT VERTEBRAL  
injection had shown.    If there is NOT an intact circle of  Willis and no cross 

circulation, then I have some other suggestions which will  come later.  
 
K Mattox.  
 
 
In a message dated 6/29/2008 11:11:01 A.M. Central Daylight Time,  
sjasmd at aol.com writes:


A 22  yo male sustained a left zone III neck stab wound that amputated his 
ear. He  exsanguinated in the field. Intubated, resuscitated, bleeding from ear 
wound.  Packing was unsuccessful. A Foley catheter was inflated in the wound 
with  reduction in bleeding. Angiogram requested shown below.


how to  proceed


sal

-------------- next part --------------
A non-text attachment was scrubbed...
Name: 1425345_ICA-ECA-INJ_31.jpg
Type: image/pjpeg
Size: 18588 bytes
Desc: not available
URL: <http://list.mistral.net/pipermail/trauma-list/attachments/20080629/4e60efc6/attachment.bin>