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Fri May 2 18:07:55 BST 2008

The CXR concerns me and I would certainly be concerned regarding an aortic
injury (especially given the mechanism of injury.) I have not seen the CT
head scan so would need to see it to see how severe the SDH is clinically
and whether or not this needs to be evacuated with Burr
holes/craniotomy/decompressive craniectomy (latter if contusions are severe
and causing problems.) If not severe from a head injury point of view, I
would just ICP monitor in this respect. SAH would be treated with formal
cerebral angiography to identify true blushes (reducing VOMIT) with
appropriate embolisation. I would try and avoid going into his head if he
has "many skull fractures" although I would ascertain this from the CT head
first.

Because he would get a formal cerebral angiogram, he would also get a form
aortic & arch aortography at the same time - as the next step after CT
thorax/aorta - to truly ascertain if there is any aortic injury/intimal
dissection. I would need to see more slices of the CT thorax to get a better
idea of what injuries the patient "probably" has, as the slices I have seen
are inadequate for me to form a proper opinion. This doesn't really matter
because I would want a formal angiogram anyway to decide further management.
Regarding the aorta I would proceed from there depending upon what it
showed. Some would opt for a delayed open repair (once he has improved from
the head injury - given his young age and the concern of long term outcomes
for stenting.) Others would opt for stenting given his co-morbidities
(especially being swayed by the head injury) as this would be an ideal
indication for stent deployment in others' opinions.

Either way, keep ventilated (as per normal neuroITU care for head injuries)
and maintain CPP (whilst reducing ICP) using minimal fluid resuscitation
(e.g. 7.5% hypertonic saline +/- starch - better than mannitol.) We have
adapted a lower target range for CPP than we previously used to. This makes
keeping the BP as low as possible (from the potential aortic injury point of
view) much easier. I would also put him on an IV beta-blocker such as
labetolol to keep his BP down pending further treatment (if any) as a result
of the aortic & arch angiography.

Matthew

-----Original Message-----
From: daniel simon [mailto:danielsimonster at gmail.com] 
Sent: 01 May 2008 16:29
To: trauma-list at trauma.org
Subject: unusual case

43 year old motorcycle crash victim , on scene intubation for GCS of 5. On

admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7 (T) .

PE: skin lacerations and  central hematoma anterior neck - zone 1.

Head CT - SAH, Frontal contusions,small Frontal SDH, many skull fractures.

C-spine:  fracture of C1

Chest XR and relevant cuts from the chest  CTA included.

Abdominal CT normal

What would you do now?

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