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Sun May 24 11:46:40 BST 2009

Sanjay
Any neurological dysfunction (perceived or otherwise) is far more likely to
be from brachial plexus involvement than from vascular compromise if the
limb is viable.  I don't think you can justify calling for hard evidence to
support CT Angio versus angiography when you have anticoagulated him without
good evidence - a much more risking intervention than a diagnostic angio.

Not that I am promoting a diagnostic angio - there's no indication here in
my view if you're not going to intervene.

However you could argue that (as you are a believer in anticoagulation) a
diagnostic angio to exclude an injury and allow him to come off the
anticoagulation is an overall lower risk course than 6 months (or whatever)
of anticoagulation without a clear diagnosis.

Karim

2009/5/23 Sanjay Gupta <sanjaygupta99_91 at yahoo.com>

>
> Thank you Karim.  That is what I am planning on doing, except for the
> addition of anticoagulation to keep INR about 2.5.  May be over-treatment,
> but the CT angio films are very compelling - clinical data including the
> subjective numbness in the arm and a corresponding swelling in the posterior
> triangle of the neck makes me think that this is real and not VOMIT.  I
> specifically looked for an injury and requested a CT angio of the subclavian
> vessel, it wasn't a radiologist call on a routine chest CT.  The patient
> refuses (and I refuse too) an angiogram.  The limb is non-ischemic, the
> lesion is well distal to the vertebral and the patient understands the risks
> and benefits both of anticoagulation and of an angiogram.
>
>
> Are there any good studies comparing the sensitivity and specificity of CTA
> versus angiogram????
>
>
>
>
> Sanjay Gupta
>
>
>
> --- On Sat, 5/23/09, Karim Brohi <karimbrohi at gmail.com> wrote:
>
> > From: Karim Brohi <karimbrohi at gmail.com>
> > Subject: Re: Subclavian artery intimal injury
> > To: "Trauma and Critical Care mailing list" <trauma-list at trauma.org>
> > Date: Saturday, May 23, 2009, 5:02 AM
> > If the limb is viable and the CT does
> > not show extravasation then I would
> > leave well alone.  I would duplex the arm in a couple
> > of weeks to make sure
> > there is no pseudoaneurysm formation.  I would
> > intervene only if the patient
> > developed disabling claudication symptoms or the vertebral
> > was involved.  I
> > would angio & ?stent an ischaemic limb only,
> > recognizing that the stent is
> > probably only going to be a temporising device.
> > Karim
> >
> >
> > 2009/5/23 Sanjay Gupta <sanjaygupta99_91 at yahoo.com>
> >
> > >
> > > No angio.  Only CT angio. Patient
> > asymptomatic.  Is a formal angiogram
> > > warranted at all if everyone on the trauma list thinks
> > it is VOMIT?  Why
> > > expose the patient to an invasive procedure with a
> > significant risk of
> > > complications - specially as she has no symptoms?
> > >
> > >
> > > Sanjay Gupta
> > > Tel: 207 576 3296
> > >
> > >
> > > --- On Fri, 5/22/09, Gross, Ronald <Ronald.Gross at baystatehealth.org>
> > > wrote:
> > >
> > > > From: Gross, Ronald <Ronald.Gross at baystatehealth.org>
> > > > Subject: RE: Subclavian artery intimal injury
> > > > To: "'Trauma and Critical Care mailing list'"
> > <trauma-list at trauma.org>
> > > > Date: Friday, May 22, 2009, 5:15 AM
> > > > VOMIT?  What did the angio look
> > > > like?
> > > >
> > > > Ron
> > > > -----Original Message-----
> > > > From: trauma-list-bounces at trauma.org
> > > > [mailto:trauma-list-bounces at trauma.org]
> > > > On Behalf Of Sanjay Gupta
> > > > Sent: Thursday, May 21, 2009 5:10 PM
> > > > To: Trauma and Critical Care mailing list
> > > > Subject: Subclavian artery intimal injury
> > > >
> > > >
> > > > 30 yrs old healthy motor cycle rider, slipped and
> > went over
> > > > a guard rail.  Came in complaining of pain
> > in right
> > > > shoulder and some numbness in rt upper
> > extremity.
> > > > Objectively, all sensory and motor function in
> > this
> > > > extremity was normal.  Blood pressure in
> > this extremity
> > > > was equal to the opposite side.  Had some
> > swelling in
> > > > posterior triangle of neck on the right side very
> > low down
> > > > in the neck.  Transverse non-displaced
> > fracture of
> > > > right clavicle in the mid-portion.
> > > >
> > > > CT angio was done because of the swelling in
> > posterior
> > > > triangle.  Showed an intimal flap with
> > thrombus with no
> > > > proximal dilation, good distal flow and
> > approximately 50%
> > > > compromise of the lumen. Injury was distal to
> > origin of
> > > > thyrocervical trunk.  No extra-vasation of
> > > > contrast.  I will post pictures soon.
> > > >
> > > > Any advice on management of this patient.  I
> > have
> > > > anticoagulated her and given her a sling for the
> > clavicle.
> > > >
> > > >
> > > > Sanjay Gupta
> > > > Tel: 207 576 3296
> > > >
> > > >
> > > >
> > > >
> > > > --- On Thu, 5/21/09, khumar huseynova <khumarhuse at yahoo.ca>
> > > > wrote:
> > > >
> > > > > From: khumar huseynova <khumarhuse at yahoo.ca>
> > > > > Subject: Re: Australian doctor uses
> > household drill to
> > > > save boy
> > > > > To: trauma-list at trauma.org
> > > > > Date: Thursday, May 21, 2009, 11:50 AM
> > > > > absolutely amazing. I know from
> > > > > experience that this is also part of
> > practice in
> > > > developing
> > > > > countries-use whatever in hand to help out.
> > > > > KH
> > > > >
> > > > > Message: 4
> > > > > Date: Wed, 20 May 2009 15:58:33 -0700 (PDT)
> > > > > From: Charles Brault <c_brault at yahoo.com>
> > > > > Subject: Australian doctor uses household
> > drill to
> > > > save
> > > > > boy
> > > > > To: Trauma and Critical Care mailing list
> > <trauma-list at trauma.org>
> > > > > Message-ID: <872592.21536.qm at web36507.mail.mud.yahoo.com>
> > > > > Content-Type: text/plain;
> > charset=iso-8859-1
> > > > >
> > > > >
> > > > > ?
> > > > > ?
> > > > > Australian doctor uses household drill to
> > save boy
> > > > > Provided by: The Canadian Press
> > > > > Written by: THE ASSOCIATED PRESS
> > > > > May. 19, 2009
> > > > > MELBOURNE, Australia- A doctor in rural
> > Australiaused
> > > > a
> > > > > household drill to bore a hole into the
> > skull of a boy
> > > > with
> > > > > a severe head injury, saving his life.
> > > > > Nicholas Rossi fell off his bike on Friday
> > in
> > > > Maryborough,
> > > > > hitting his head on the pavement, his family
> > told The
> > > > > Australian newspaper in a story published
> > Wednesday.
> > > > > By the time Rossi got to the hospital, he
> > was slipping
> > > > in
> > > > > and out of consciousness.
> > > > > The doctor on duty, Rob Carson, quickly
> > recognized
> > > > the
> > > > > 13-year-old was experiencing potentially
> > fatal
> > > > bleeding on
> > > > > the brain and knew he had only minutes to
> > drill a
> > > > hole
> > > > > through the boy's skull to relieve the
> > pressure.
> > > > > But the small hospital was not equipped
> > with
> > > > neurological
> > > > > drills - so Carsongrabbed a household drill
> > from the
> > > > > maintenance room.
> > > > > A Melbourneneurosurgeon talked Carsonthrough
> > the
> > > > procedure
> > > > > by telling him where to aim the drill and
> > how deep to
> > > > go and
> > > > > soon, a blood clot fell out, relieving the
> > pressure on
> > > > the
> > > > > boy's brain.
> > > > > "Dr. Carson came over to us and said, 'I am
> > going to
> > > > have
> > > > > to drill into (Nicholas) to relieve the
> > pressure on
> > > > the
> > > > > brain - we've got one shot at this and one
> > shot
> > > > only,"' said
> > > > > the boy's father, Michael Rossi.
> > > > > Rossi was airlifted to a larger hospital in
> > > > Melbourneand
> > > > > released Tuesday - his 13th birthday.
> > > > > Carsonwas modest about his feat.
> > > > > "It is not a personal achievement, it is
> > just a part
> > > > of the
> > > > > job and I had a very good team of people
> > helping me,"
> > > > he
> > > > > told the newspaper.
> > > > > Michael Rossi was more effusive.
> > > > > "He saved our son's life," he said.
> > > > > ?
> > > > > ?
> > > > > ?
> > > > >
> > >
> http://health.lifestyle.yahoo.ca/channel_health_news_details.asp?news_id=18129&news_channel_id=1008&channel_id=1008
> > > > >
> > > > >
> > > > > ------------------------------
> > > > >
> > > > >
> > > > >
> > > > >
> > > > >
> > > >
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Subclavian artery intimal injury