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Fri Aug 31 13:15:21 BST 2007

Zone III GSW with obvious vascular injury, probably ICA but could be any  
branch of ECA, resusticate, endotracheal tube if possible, cspine not relevant,  
finger in the hole, angio in a hurry, selective internal  and external  
carotid angios. if ica injury, intermittent balloon occlusion and continue four  
vessel cerebral assessment. if possible repair with stent graft. if not  
possible, embolize and hope for the best.

if external branch, ie posterior auricular, external carotid, occipital  then 
coil occlusion. 

No angio available, compression and a prayer

sal

In a message dated 8/31/2007 6:34:17 A.M. W. Europe Daylight Time,  
wildmedic at gmail.com writes:

This one  just in.  Your management?

40-something male hijacking victim  brought in off the street by
companions with transaxial GSW to the  neck.  Entry at left mandible
with ramus fracture; exit just anterior  to right external auditory
meatus.  On arrival in our resus unit the  patient is making gurgling
attempts at respiration and has rapid weak  radial pulse.  GCS 6 with
equal reacuve pupils; restless; moving all  limbs.

1) Do you immobilise c-spine?

We commenced with  RSI...

2) What drugs?
3) Endotracheal or surgical  airway?

...and established bilateral large IV's.  Initial BP was  71/33, HR
130.  Rapid infusion of Ringer's Lactate (1500ml) brought BP  to 96
systolic but spurting arterial bleeding from the exit  wound.

4) Oversew, foley's tamponade, pack or just a pressure  dressing?
5) What BP should we target? Permissive hypotension or  normotension?

Patient continues to be  restless.

6)Sedation?
7) Analgesia?

The patient was  stabilised to the point at which doom was not
immediately impending.   A plain chest film confirmed our tube
placement and demonstrated aspiration  (presumed blood).  Orogastric
tube in situ; urinary catheter drained  300ml.  No other injuries on
survey.

What's the next  step?
What imaging are you wanting?
What interventions do you  plan?

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