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BEST CASE OF MY CAREER

Timothy Craig Hardcastle TimothyHar at ialch.co.za
Mon Jun 30 07:00:18 BST 2008


Coming into this one a little late (weekend off!), but my concern is
when you embolize the ICA / Prox ECA, when the foley tamponade is
removed, what about back bleeding from the distal ends?

I hear you want to go higher through the clot, but if you now embolize
clot and cause a stroke, you have potentially done more harm.

My approach would be: embolize the ICA just distal to the bifurcation,
select ad coil the ECA branches and then remove the catheter after 48
hours in the OR with the area cleaned and draped so as to go in and tie
any residual bleeders. In my experience this usually works well.

Regards
Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban
 
Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal
 
timothyhar at ialch.co.za 
 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of sjasmd at aol.com
Sent: 29 June 2008 22:27
To: trauma-list at trauma.org
Subject: Re: BEST CASE OF MY CAREER

Ken
your points are all good. When I first arrived he was intubated and
fighting the ventilator and seemed to calm down when i instructed him to
relax and let the blower breath for him. He was moving all his
extremities. Perhaps his agitation had to do with severe anemia and
cerebral insufficiency but I dont think he had any focal signs upon my
arrival. After that we sedated him with atavan.

The angiogram whose lateral view was the only one that you saw? revealed
an occluded internal carotid artery and a fairly high injury of the
external carotid artery. Given the location of the external carotid
injury, i presumed that the injury of the ICA was also fairly high and
that the more proximal occlusion merely represented clot that had
propogated down. There were also two ECA branches that were bleeding,
but not visualized without selective catheterization of the occipital
and the posterior auricular branches.

By the way, good pickup on the collateral flow to the ophthalmic from
the internal maxillary artery.

As is standard practice, any injury of the carotid or vertebral arteries
found by angiography warrants full angiography of both carotids and both
vertebral arteries. The left vertebral arteriogram (attached) showed
prominent collateral flow from the vertebral through the posterior
communicating artery. The right carotid and vertebral arteriograms did
not show flow to the distribution of the left internal carotid artery.

OK, so you would like the internal carotid artery embolized. The
question that comes up is should the occluded vessel be secured with
some coils proximally. Or would you like me to advance the catheter
through the clot in the hopes that I can get into the distal ICA and do
embolization there first.

Hold on to your ideas about what to do without an intact Circle of
Willis for the moment. Lets get back to that strategy later.


sal


-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Sun, 29 Jun 2008 12:23 pm
Subject: Re: BEST CASE OF MY CAREER



First, Sal thanks for the Case for us to review.   I was on duty  as
well 
yesterday and also had a CAROTID injury, but we went directly from the  
ambulance 
dock to the OR and did not have benefit of an angiogram.  
 
In your case:   We have basically ONE  view.     I cannot make out the 
"balloon" or what it  occludes.    You have asked for opinions as to
"What to do  

NEXT?"     I see NO intracerebral circulation, but I think I  see
ophthalmic 
vessels from the left external carotid circulation.    We do not have
any 
description of the status of the patient now that left  external carotid
is 
occluded. 
    If the patient is viable,  I would request of YOU, now that you are
in 
the arteriogram suite to inject the  RIGHT carotid artery and look at
the cross 
circulation.    If the  patient is CNS intact, and there is CROSS
circulation 
with an intact circle of  Willis, I would ask you then totally occlude
the 
Left Internal  Carotid.    I would like to know what your LEFT VERTEBRAL

injection had shown.    If there is NOT an intact circle of  Willis and
no cross 

circulation, then I have some other suggestions which will  come later.

 
K Mattox.  
 
 
In a message dated 6/29/2008 11:11:01 A.M. Central Daylight Time,  
sjasmd at aol.com writes:


A 22  yo male sustained a left zone III neck stab wound that amputated
his 
ear. He  exsanguinated in the field. Intubated, resuscitated, bleeding
from ear 
wound.  Packing was unsuccessful. A Foley catheter was inflated in the
wound 
with  reduction in bleeding. Angiogram requested shown below.


how to  proceed


sal



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