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Wed Jul 4 09:49:23 BST 2007

Sanjay,

Agree with Mike and Marshall. Level 1 evidence is completely absent...it is
all eminence based. Our practise (tertiary vascular unit with buckets of
blunt trauma through the hospital) is to do CTA or MRA with a dedicated neck
coil; or duplex if the lesion is in zone 2 (they are often above this in
spontaneous dissection, and a large number of skilled vascular technologists
will still not be able to adequately demonstrate the lesion even when
insonatable), and anticoagulate for 3/12 minimum.  As Marshall states...in
the initial phase, if you have TCD available, then ongoing embolisation is
an absolute indication for anticoagulation.  
The other option in the immediate peri trauma period where systemic heparin
or coumadin anticoagulation may be contraindicated is dextran 40 infusion -
Ross Naylors group in UK have found it decreases perioperative stroke in
embolising post-CEA patients and that may be able to be loosely extrapolated
to the dissection group.  Also Jay Yadhavs group have had some success with
stenting in the symptomatic spontaneous dissection group...might be a
further option (altough these patients need clopidogrel as well).  IN NZ we
don't have the freedom to use clopidogrel in this indication, however it
would seem to be reasonable in the absence of a head injury (the Brain
surgeons would have a heart attack if we suggested it for anyone with a
demonstrated intracranial haemorrhage in NZ/Oz)

Cheers,
Mark Hamilton 
Vascular and Endovascular Surgeon
Waikato Hospital, Hamilton, NZ

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Karim Brohi
Sent: Tuesday, 3 July 2007 9:25 p.m.
To: Trauma &amp, Critical Care mailing list
Subject: Re: Carotid artery dissection

Sanjay

As Mike says, there is little evidence to support intervention, and even
less to support one over the other.  We have very little idea of the natural
history of the condition.  Her confusion is not related to the carotid
artery injury.

I think you need to confirm presence of the dissection with a formal duplex
ultrasound performed by a vascular technologist. If present, and without
other contra-indications, you probably should anticoagulate her.  Probably
heparin->warfarin but aspirin may be adequate (no evidence of course).

Be nice to see the CT scans if you can email them or upload your case to the
website

Karim

On 03/07/07, Marshall Colette (RKB) Consultant Surgeon Vascular <
Colette.Marshall at uhcw.nhs.uk> wrote:
>
> You might find transcranial Doppler monitoring of the middle cerebral 
> artery useful here - it will tell you if there is any ongoing 
> embolisation to the brain - if there is then the patient is at high 
> risk of stroke.  By 12 days any clot attached to the dissection 
> probably will have stabilised and hopefully the high risk period for 
> stroke will be over.  Long-term anticoagulation obviously has to be 
> balanced against the risk of bleeding from the traumatic injuries.  
> Anti-platelet medication (clopidogrel or
> aspirin) would be an alternative to consider and perhaps slightly less 
> risky in terms of bleeding.  There is no high level evidence that I am 
> aware of to suggest which is the preferred approach. At Coventry we 
> have successfully used tirofiban in a trauma patient with bilateral 
> carotid dissections to reduce the stroke risk but in trauma this is 
> risky - this patient developed a retroperitoneal haematoma and 
> treatment had to be stopped.
>
> Colette Marshall
> Consultant Vascular Surgeon
> University Hospital Coventry and Warwickshire UK
>
> -----Original Message-----
> From: Sanjay Gupta MD [mailto:sanjaygupta99_91 at yahoo.com]
> Sent: 02 July 2007 21:04
> To: Trauma &amp, Critical Care mailing list
> Subject: Carotid artery dissection
>
> Dear Trauma List members,
>
> I have a difficult problem.
>
> 30 years female patient. Motor vehicle collision.
> Pelvic fracture, spleen rupture, bladder rupture, small subarachnoid 
> bleed.  Hypotensive at arrival -underwent ex-lap, splenectomy, bladder 
> repair.  Did well with these injuries, but remained disoriented after 
> extubation for a long time.  One of our partners called a neurology 
> evaluation, who as a part of their evaluation ordered a CT angiogram 
> of the head which revealed a high dissection of the left carotid 
> artery.
> The head CT is otherwise normal. Radiologist is sure it is there.  The 
> patient moves both sides of her bodies.  The angiogram was done on the 
> 12th day after trauma.  No obvious focal deficits - sensory or motor.
> Her sensorium is gradually improving.  However, neurosurgeons and 
> neurologists want to anticoagulate the patient for a minimum of 3 
> months.  I am not sure if this will help.
>
>
> Any input would be appreciated.
>
>
>
> Thanks
>
> Sanjay
>
>
>
>
>
> --- "Hardcastle, Tim, Dr <tch at sun.ac.za>"
> <tch at sun.ac.za> wrote:
>
> > Jose
> >
> > I can't talk about level of evidence on this one - only personal and 
> > institutional experience, namely that most children who present 
> > frankly hypotensive for age, without adequate fluids (we try to use 
> > blood products early) to at least get them back to a reasonable 
> > baseline pressure (70+2Xage) have died, despite rapid assessment and 
> > rapid surgical intervention. We have seen a progressive tachycardia 
> > till the point of "no-return". The challenge with the small child is 
> > not the fact that they are hypotensive, rather the answer to whether 
> > the "are bleeding" or "have bled". The former group - permissive 
> > hypovolaemia - no problem -  get them to definitive surgical care - 
> > still high mortality. The latter group - surgical intervention may 
> > do more harm than good; one would rather fully resus and investigate 
> > intensively with imaging once stable.
> > The challenge is that the latter group is the vast majority.
> >
> > So in summary, it is about the decision as to whether surgery is the 
> > management of choice or rather investigae and manage SNOM, that 
> > dictates the need for formal resuscitation to normalish values.
> > Again this is for BLUNT trauma, not penetrating trauma.
> >
> > Tim
> > Dr T C Hardcastle
> > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA) Senior Surgeon / Senior 
> > Lecturer: Surgery (Trauma and ICU) ATLS  instructor and DSTC Cape 
> > Town Course Director Intern program Coordinator: Surgery M.Med 
> > (Emergency Medicine) Executive Committee member Clinical Head 
> > (Director): Diana Princess of Wales Trauma Unit Division of Surgery 
> > (General) Room 4064 Department of Surgical Sciences Tygerberg 
> > Hospital / University of Stellenbosch PO Box 19063 Tygerberg 7505 
> > Western Cape South Africa
> > e-mail: tch at sun.ac.za
> > Cell: +27824681615
> > Office: +27219389281 or 4911 pager 0302
> >
> >
> >
> >
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org 
> > [mailto:trauma-list-bounces at trauma.org]On Behalf Of JOSE SUAREZ 
> > PELAEZ
> > Sent: Thursday, June 14, 2007 2:33 PM
> > To: Trauma &amp; Critical Care mailing list
> > Subject: Re: Pre-hospital fluid therapy.
> >
> >
> > Dear Dr Hardcastle,
> >
> >
> >
> > Thank you for your comments.
> >
> >
> >
> > It is true that when a certain hypovelemia exists, increases within 
> > specific limits in cardiac frequency and vascular resistance 
> > constitute compensatory mechanisms for blood pressure. We also know 
> > that hypotension is often a late sign and that patients are always 
> > hemodynamically stable until they become unstable.
> >
> >
> >
> > For years our lecturers have warned about the existence of 
> > compensated shock, occult hypoperfusion and sudden decompensation. 
> > It is curious that two large retrospective studies found that 
> > approximately 1/3 of patients presented relative bradycardia and had 
> > better survival. This raises various questions.
> >
> >
> >
> > I think that no particular age avoids:
> >
> >   1.. Increased intravascular pressure produces increased 
> > uncontrolled bleeding and clot disruption.
> >   2.. The dose-dependent damaging effects of isotonic fluid 
> > administration.
> > What level of evidence is there in favor of normalizing blood 
> > pressure in children aged 6-8 years who present uncontrolled 
> > hemorrhage? What level of evidence is there to indicate the use of 
> > 20 ml/kg isotonic boluses?
> > According to my review of the literature, the evidence is scarce.
> >
> >
> >
> > It would be a pleasure to hear your opinions on this.
> >
> >
> >
> >
> >
> > Thank you,
> >
> >
> >
> >
> >
> > J Suárez Peláez.
> >
> >
> >
> >
> >
> >
> >
> > ----- Original Message -----
> > From: <tch at sun.ac.za>
> > To: "Trauma &amp; Critical Care mailing list"
> > <trauma-list at trauma.org>
> > Sent: Wednesday, June 13, 2007 4:58 PM
> > Subject: RE: Pre-hospital fluid therapy.
> >
> >
> > Jose
> >
> > I do have a concern about this concept in the
> > younger child - under age 6-8,
> > as their physiology IS different. The compensate by
> > progressive tachycardia
> > and maintain SBP till just too late - then drop off
> > over the waterfall and
> > DIE on you!
> >
> > For adolescents or adults I agree completely
> >
> > Tim
> > Dr T C Hardcastle
> > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> > Senior Surgeon / Senior Lecturer: Surgery (Trauma
> > and ICU)
> > ATLS  instructor and DSTC Cape Town Course Director
> > Intern program Coordinator: Surgery
> > M.Med (Emergency Medicine) Executive Committee
> > member
> > Clinical Head (Director): Diana Princess of Wales
> > Trauma Unit
> > Division of Surgery (General) Room 4064
> > Department of Surgical Sciences
> > Tygerberg Hospital / University of Stellenbosch
> > PO Box 19063
> > Tygerberg 7505
> > Western Cape
> > South Africa
> > e-mail: tch at sun.ac.za
> > Cell: +27824681615
> > Office: +27219389281 or 4911 pager 0302
> >
> >
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> > [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> > JOSE SUAREZ PELAEZ
> > Sent: Wednesday, June 13, 2007 5:25 PM
> > To: Trauma &amp; Critical Care mailing list
> > Subject: Re: Pre-hospital fluid therapy.
> >
> >
> > Dear Dr. Mattox,
> >
> >
> >
> > Thank you for your comments. The objective of my
> > email was to hear different
> > opinions from colleagues on certain issues.
> >
> >
> >
> > I believe that while SBP continues to be used as the
> > main therapeutic
> > objective in bleeding patients, while the
> > means/devices to measure SBP are
> > maintained and not replaced/complemented by other
> > more sensitive measures
> > (SLCO2, NIRS, etc) to detect acceptable perfusion
> > indicating
> > non-administration of fluids (to avoid greater
> > hemorhage, re-bleeding and/or
> > a systemic inflammatory response due to unnecessary
> > fluid administration),
> > SBP will continue to constitute the golden objective
> > in pre-hospital
> > treatment and set back the day when bleeding
> > patients are not given
> > excessive quantities of fluid that may result in
> > devastating consequences,
> > whether immediate or not.
> >
> >
> >
> > You and other experts have warned about the
> > limitations of SBP as
> > therapeutic objective and have proposed the use of
> > permissive hypotension.
> > However, quantities of isotonic fluids >750 ml may
> > continue to be
> > administered. I think the didactic use of the
> > concept permissive hypovolemia
> > (and not hypotension) might help to reduce excessive
> > administration of
> > fluids: attempting to provide each patient with only
> > what he/she needs,
> > specially in children.
> >
> >
> >
> > There are sufficient arguments against the need to
> > normalise BP in bleeding
> > patients. I think the scientific community is
> > tending towards this
> > viewpoint.  But how to ensure the administration of
> > the necessary fluid to
> > achieve a balance between damage and benefit? As the
> > Dutton study has shown,
> > this is complicated.
> >
> >
> >
> > Perhaps, as you propose, 50 ml boluses using radial
> > pulse and state of
> > consciousness as endpoints, regardless of BP, could
> > prevent situation like
> > following: my nurse Toñi usually has BP of 70, in
> > the event of an accident,
> > she could be hypotensive, tachycardic, anxious, etc,
> > so, she would probably
> > receive excessive fluid possibly causing increased
> > bleeding, re-bleeding,
> > iatrogenic respiratory distress, or even multi-organ
> > failure and death,
> > after hemorhage control and a "normal" BP.
> >
> >
> >
> > Therefore I believe we should start to use the term
> > Permissive Hypovolemia,
> > not merely for semantic reasons but because of its
> > conceptual and didactic
> > usefulness.
> >
> >
> >
> > I would be grateful for any comments you may have
> > (pro or cons)
> >
> >
> >
> >
> >
> > José Suarez-Peláez
> >
> >
> >
> >
> >
> >
> > ----- Original Message-----
> > From: <KMATTOX at aol.com>
> > To: <trauma-list at trauma.org>
> > Sent: Tuesday, June 05, 2007 12:09 PM
> > Subject: Re: Pre-hospital fluid therapy.
> >
> >
> >
> > In a message dated 6/5/2007 5:27:34 A.M. Central
> > Daylight Time,
> > josuarez at teleline.es writes:
> >
> > José  Suarez-Peláez
> >
> >
> >
> > Dr.  Jose Suarez-Pelaez has asked this group to
> > respond to an article  and a
> > letter to the editor in the journal, "Injury."
> > The  letter contains some
> > germane observations and questions.    Particularly,
> > the question of the
> > value
> > of systemic blood pressure as a measure  of adequacy
> > of resuscitation,
> > perfusion, etc. is right on.     However, for the
> > majority of the world,
> > this readily
> > available device is what is  available, and Near
> > Infrared Spectroscopy has
> > not
> > yet been  standardized.
> >
> > I would agree that in the referenced study, the
> > inclusion criteria are two
> > broad and using a BP of 90/- systolic, or better
> > 70/- as an entry criteria
> > for
> > such studies would be more appropriate.
> >
> > K Mattox
> >
> >
> >
> > ************************************** See what's
> > free at
> > http://www.aol.com.
> > --
> > trauma-list : TRAUMA.ORG
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>
>
> Sanjay Gupta MD
> Tel: 412 335 6304
>
>
>
>
>
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Carotid artery dissection