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A 25 year old male presented to the Parkland Memorial Hospital Emergency Room with a single gunshot wound to the body of the left mandible. He had been intubated in the field, and was moving all extremities on arrival. Intraoral hemorrhage was controlled by packing his mouth with a roll of Kerlex.

The lateral cervical spine film shows that the fragments had traversed Zone II of the left neck.

As his hemorrhage was controlled by packing, the patient was then taken to angiography. The anterior view of the left common carotid angiogram shows complete disruption of the carotid artery with comminuted mandibular fracture.

The lateral view shows external carotid extravasation and internal carotid thrombosis.

The patient was then taken to the operating room for exploration of his neck through a left anterior sternocleidomastoid incision.

Contusions of the internal and external carotid arteries were noted with a laceration of the external. In the image below, the common carotid has been divided just proximal to the injury, and the contused external and internal carotids are plainly visible as the transected stump of common carotid is rotated cephalad.

Above, the injured area has been excised. The external carotid stump has been ligated, and the internal and common carotid arteries have clamps on them.

A reversed saphenous vein graft was then used to reestablish flow from the common carotid to the internal carotid artery.

The final incision with the mandibular entrance wound. The patient awoke neurologically intact and had an uneventful convalescence prior to being discharged home.

Submitted by: Herb Phelan, Brian Eastridge, Parkland Memorial Hospital, Dallas, Texas

Comments

On 10/26/2007, walmargol commented:

Hi, Im Dr Walter Mariaca Im from Bolivia but I live and work in paraguay, just a week ago i treated a patient with a similar damage, i could not make the angiography, because in my hospital we don have that equipment, but i did the exploration and i found a laceratión of the common carotid artery, i made a bypass whit the homolateral yugular posterior vein, the patient had a good recovery and he went home 4 days after surgery, mi questión is to know if my procedure was correct, mi colegs are not agree with mi procedure, please answer my doubts. thanks a lot
Dr. Walter Mariaca Golac, Trauma surgeon

On 11/30/2007, sarfile commented:

I do agree with Dr Walter and his presence of mind. Dear Dr Walter can you give details of followup of the patient and any investigation done pre and post operative to confirm the patency of vessels.

On 11/30/2007, sarfile commented:

Dear Dr Walter even you have no access to angiography and wound explored and you know the type of damage so its more safer to do graft with saphenous vein than jugular. please put your reason for using jugular instead of saphenous.

On 11/30/2007, walmargol commented:

Thanks for your comments,  i dont have acces to the files of the patien treated, but i know tha he came back to his control with no difficults, the reason i esued the external jugular vein jugular was the time an the acces, i didt have to workmin another part of the boy loking for a vein, and the otrer reason was that in the OR i was the only capable to do that procedure so i think to do faster the procedure to avoid any problems of hipoxia cerebral, well that is what i thik at the moment, after the surgery i change mi mind, but the desition to make it was in the mommment, Thanks for your comments and for your help.

On 12/01/2007, sarfile commented:

Dear Dr Walter you did the right job to save time but as far as cerebral hypoxia is concerned I do not think so.God has made circle of willis for this moment to save the brain from anoxia.

On 12/26/2007, christine horman commented:

I NOTICED THAT AT THE END OF THE PROCEDURE IT WAS SAID THE PATIENT WAS NEUROLOGICALLY INTACT,WHAT IF ANY NEUROLOGIC COMPLICATIONS COULD BE PRECIPITATED IN THE POSTOPRETIVE PERIOD?christine horman

On 01/20/2008, taiwo commented:

The challenges of working in a resource limited environment is enormous. We are incapacitated not only by facilities often regular update courses is not available to keep abreast with the rest of the world. Kudos to those who forge despite these hoping one day that the paradigm would shift.

On 03/25/2008, Ragdolly commented:

re comment 01/17/08 its not a fork its spreader equipment to hold the tissue out of the way. If you look at the image above you will see the item from a different angle.

On 04/16/2008, Tim Hardcastle commented:

Just a thought

Did you really need the angio - a zone 2 GSW with active bleeding should be empirically explored?

Tim
South Africa

On 05/02/2008, Dr. Pachy commented:

in patient with zone II injury, you have to qualify first if the zone II injury have soft or hard signs, meaning if you only have soft signs you have time to work up the patients with angio but if your patients does have hard signs,  is amandatory exploration.

On 07/30/2008, george.oost commented:

Agree with Tim’s sentiments, although in this case one might contemplate the possibility of a zone 1 injury, in view of the scattered nature of the bullet fragments. It appears the bleeding was readily controlled and the patient was stable, clearing the way for imaging.

George
South Africa

On 08/05/2008, alsayali commented:

Hi
In stable patient with this kind of injury .What is the role of CT angio?
I mean, it can give mroe detailed about other structurs injured .

alsayali
Melbourne

On 01/30/2009, george.oost commented:

With CT there is a possibilty of “scatter” due to the bullet fragments; however this is much less of a problem with the newer generation scanners. We would do a quick first scan without contrast to see if there is scatter in the areas of concern. If not, we would then proceed with a contrast scan (CT angio). The vast majority of scans would be sufficient. We would reserve formal angiography for cases with scatter on the first scan or for those who go on to have an unclear CT angio due to bullet artifact. However, to give a second large dose of IV contrast, a 24 hour delay is advised. Hence, if there is clinical suspicion of vascular injury, your hand may be forced at this stage.

On 07/12/2010, chumrooreshad commented:

I agree with Dr Hardcastle and facilities for angiogram is not always available out of hours.

On 05/28/2015, Dr. Ivan commented:

In my point of view,  the hemorrhag controlling and the fast intubation was a priority in saving the patient’s life. The first procedure was correct, which was at immediately intubation in the field, if this action wouldnt have been performed, the pronostic would have been other. To act quickly is a priority while assisting in this patient’s situation, from the air way was needing priorizing acting, this won time for the surgeos to perform the angiography and to add the saphenous vein graft for the bledding corretion intervention that is why the surgeons could safe the a patient’s life.

Mexico EMM- Student
Ivan Hernandez Blancas

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