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Mon Aug 20 17:29:35 BST 2007

Thanks for the arteriogram, Sal.     It was helpful to  me for the following 
reasons:  

1.    I saw BOTH vertebrals coming off of the  respective subclavian 
arteries. 
2.    I see the area of injury just distal to the take  off of the common 
innominate/carotid trunk takeoff and proximal to the takeoff  of the Left Carotid 
artery
3.    The amount of extravasation is relatively  small
4.    The patient is intubated
5.    An NG tube is in place
6.    There is a blip on the right subclavian artery,  but I do not believe 
it is an injury.  

I would NOT want to "try" a stent.   I do not think it is  stentable.    If 
this patient is stable hemodynamically, and  with the arteriogram shown, and 
with the descriptions and information we have, I  would NOT operate on his neck 
and mediastinum RIGHT NOW.     

Why is he intubated?    Did he aspirate?  He is NOT now  bleeding to death 
and he does NOT have an obstructed airway in the  neck.     We were told about 
some altered mental status and  now he is intubated and we do NOT know about 
his overall clinical  condition.     We have the GSW in the thigh that is still  
out there with no new information shared with us.       I would take him to 
ICU and bed him down and get more data.     Has he had some brain anoxia or 
hypoxemia.   What are his blood  gasses.    Get him more stable and we will 
decide TOMORROW about  the timing and the approach to his innominate artery injury. 

I do have a game plan if I am suddenly forced to operate, but right now, I  
WOULD NOT GO TO THE OR.     

k

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Innom GSW: DO NOT OPERATE NOW