BEST CASE OF MY CAREER- PART TWO

[Timothy Craig Hardcastle]

Sal

Exactly what I asked about / suggested earlier - distal end backbleeding
- leave the Foley catheter inflated for 48 hours and try again. It
should clot up. Otherwise move to OR and go and ligate the distal end.
Obviously there is "adequate" collateral flow!

If you are really good (like I know you are) you could go through the
circle of Willis with Micro-catherters and embolise the ICA from inside
the brain (seen it done once in Tygerberg - crossover from one vertebral
to the other to coil a vertebral AV fistula. Takes a bit of time though.

What is his Lactate and temp / pH at this point and how much blood has
he lost?

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban
 
Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal
 
timothyhar at ialch.co.za 
 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of sjasmd at aol.com
Sent: 30 June 2008 14:26
To: trauma-list at trauma.org
Cc: daniel.levin at downstate.edu; rick.hoffer at gmail.com;
MICHAEL.HERSKOWITZ at DOWNSTATE.EDU; huntz.liu at downstate.edu;
ERICH.LANG at DOWNSTATE.EDU
Subject: Re: BEST CASE OF MY CAREER- PART TWO

I decided that an attempt at stent graft of the external carotid artery
had merit in order to maintain the ophthalmic artery collateral and
because this would have treated the occipital, posterior auricular and
external carotid injuries simultaneously even if it occluded. I thought
that the graft had low likelihood of success because of the preexisting
post traumatic vasospasm and the small size of the vessel, but i didnt
think it would hurt to try.. 

A 5mm? diameter 22mm Atrium stent graft was placed over the injured
segment of the ECA and the orifices of both branches. It occluded within
minutes. 

The proximal ICA occlusion was secured with three gianturco coils. I
chose NOT to try to go through the clotted ICA to the other side?of?this
injury for fear of dislodging and embolizing clot into the brain.? 


There was still bleeding from the wound but when the balloon was
deflated, there was torrential bleeding. We intermittently let down the
balloon and repeated the angiography of the carotid and remaining
external carotid branches without seeing any extravasation.? So we
repeated angiography of all remaining three cerebral vessels. The left
vertebral angiogram is attached.





-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Sun, 29 Jun 2008 10:25 pm
Subject: Re: BEST CASE OF MY CAREER
I have seen the second set of images.    I would also  consider
DEFLATING the 
tamponading balloon for a few seconds in order to obtain  a view.   It
may be 
that the internal carotid artery is occluded ONLY  by the occluding
balloon.  
 
k
 
 
In a message dated 6/29/2008 9:20:14 P.M. Central Daylight Time,  
jduchesn at tulane.edu writes:

sal-  good save!.........is the patient awake? Any lateralizing signs?
I agree  with Norm. Based on this angio view the injury can be approach
thru 
formal  sternocleidomastoid approach........I favor repair before 
ligation........  although looks like the ophthalmic artery collateral
is open 
like Dr 
Mattox  well mention 
Good case
j
CharityOne

Juan C Duchesne MD, FACS,  FCCP
Trauma and Critical Care Surgery Section
Surgical Hospital Center  Director
Director Surgical Intensive Care Unit  
Louisiana ATLS /  PHTLS State Faculty