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Mon Aug 20 20:29:23 BST 2007

I see the argument for not operating.  But...

This gentleman as originally presented had an altered
mental status whose etiology wasn't clear.  High on my
differential included:
-hyporesusctation
-closed head injury
-penetrating head injury
-embolic stroke
-drug/alcohol intoxication

Assuming now that he is now adequately resuscitated
and not paralyzed and that his ETOH levels are normal
and he has no other mind altering street drugs in his
system and that his CT of the head is unrevealing for
injury then I am left with stroke (which if may not be
revealed on a early head CT).  

If you then consider the innominate as a proximal
embolic source then would you be compelled to repair
him early?  

Sal, did you do a 4 vessel angio as well?

Ben Reynolds, PA-C
Pittsburgh, PA
--- KMATTOX at aol.com wrote:

> 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