|
CLASSIC CASES
Non-operative management
of thoracic vascular Injury
Case
Presentation
This was a 34 year old male who suffered a low velocity gunshot
wound to the left upper chest, presenting with a 1cm wound just
under the left midclavicle as a sucking chest wound. This wound
was sutured close and a left tube thoracostomy placed, which initially
put out 300cc blood. There was an apparent exit wound on the upper
right back over the mid right scapula. Physical exam showed complete
sensorimotor loss below the nipples and no rectal tone, consistent
with a spinal cord injury at T4. Distal pulses were all present
and equal in all 4 extremities.
Patient's vital signs initially
were BP 110/70, Pulse 120, RR 30, O2 sat 97% room air. CXR showed
bullet fragments across the upper right chest posteriorly, and
a left pulmonary contusion.
After the chest tube was placed,
BP intermittently dropped into the 80's, and over the course of
the next 4 hours a total of 1000cc blood came out the left chest
tube. Patient was intubated.
An arteriogram was performed showing
a nonocclusive and non-extravasating intimal injury of the right
innominate artery at the takeoff of the right subclavian and carotid
arteries. Left great vessels were not injured. A flexible esophagoscopy
showed no injury. It was decided to observe the patient nonoperatively.
A right chest tube was placed which did not put out any blood.
Over the next 5 days the blood from the left chest stopped, vital
signs stabilized, and the patient was extubated. A repeat arteriogram
showed complete resolution of the innominate artery intimal defect.
The patient never required surgery. He was transferred to a spinal
cord injury rehab center 10 days post injury.
|
Initial Angiogram
|
Repeat Angiogram
|
Discussion
It was clear that the innominate artery injury was not responsible
for the left chest bleeding (which was probably from the parenchymal
injury of the lung), or the hemodynamic instability, and was an
essentially incidental finding. Such nonocclusive "minimal" arterial
injuries are well documented to have a benign natural history,
and should be followed rather than being immediately operated
upon when they are asymptomatic (i.e. no hard signs of vascular
injury) with a vessel that is not occluded and has no gross extravasation,
as the majority never require surgery. A patient such as this
does not need unnecessary surgery, especially surgery as extensive
as this procedure would have to have been. His bleeding from the
left chest tube was borderline in terms of an indication to operate,
which is generally suggested when output exceeds 200cc/hour for
more than 4 hours. Fortunately it tapered off.
Reference
Frykberg ER, et al: 'Nonoperative
Observation of Clinically Occult Arterial Injuries - A Prospective
Evaluation.' Surgery 1991;109:85-96.
trauma.org (5:6) June 2000
|
