Damage Control Carotid Transection

www.elsevier.com/locate/ajem

American Journal of Emergency Medicine (2008) 26, 841.e3–841.e5

Case Report

Fig. 1 The neck wound extended from zones I to II with internaland external carotid transection (white arrows) combined with othervessel injuries and laryngeal perforation.

Damage control in the transection of carotidartery—a case report

Abstract

Transection of the carotid artery is very rare in Taiwanowing to tight gun control. Most carotid artery injuries arecaused by penetration wounds as a result of stabbing orshooting. The total transection of internal and externalcommon arteries is very rarely encountered, and mostsurgeons lack experience of this intervention. We present avery rare patient who had his right neck cut caused by a flyingpiece of sheet metal during a typhoon. The case was sent toour emergency department without any vital signs. Intubationwas performed into the perforation of larynx with aggressiveresuscitation. The patient regained his heart rate and bloodpressure after several minutes of cardiopulmonary resuscita-tion. Then he was sent to operating room, where tracheost-omy was performed and bleeding was controlled by ligationof all bleeding arteries including internal and external carotidarteries. Two days later, the patient died, however. Wereviewed the literatures and discussed the case.

A 28-year-old male patient who has been injured duringa typhoon was sent to our emergency department (ED)without vital signs and was dead on arrival. Upon arrival,he was unconscious, and his pulse and blood pressure couldnot be measured. Clinically, he presented poor peripheralperfusion with pale, cool extremities, and oliguria. His rightneck had been cut by a flying sheet metal and had beencompressed by gauzes with elastic bandage by theemergency medical technicians. Cardiopulmonary resusci-tation was performed immediately with aggressive resusci-tation after direct insertion of endotracheal tube into theperforation of larynx. After several minutes, his heartstarted beating and blood pressure was elevated. Duringexploration of the wound to his neck, a life-threateningtransection injury above the bifida of the common carotidartery was found with mass active hemorrhage (Fig. 1). Tocontrol the bleeding, the trauma surgeon clamped the 2ends of external and internal carotid artery with other smallactive bleeding points by forceps. The patient wasimmediately transferred to the operating room for thevascular and larynx repair.

0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.

In the operating room, tracheostomy was performed, andthe clamped arteries were immediately ligated due to activeleaking from the wound and relative hypotension of thepatient. Laryngeal perforation was repaired, and allintervention was done within 1 hour. The patient wassent to intensive care unit (ICU) for further management. InICU, the patient's blood pressure elevated after resuscita-tion, and his bilateral pupils also had light reflex in the first12 hours. The wound leaked extensively if the bloodpressure was elevated. Then, his right pupil dilated, andbrain computed tomography showed right brain edema withleft hemisphere hemorrhage (Fig. 2). Two days after, hisblood pressure dropped, and he died as a result of centralfailure [1,2].

Injury to the artery distal to the bifida of common carotidartery is a rare event, with a poor prognosis and highmortality. Penetrating injuries to the carotid and vertebralarteries account for only 3% and 0.5%, respectively, ofarterial injuries treated in other trauma centers [3,4].Ramadan et al reported that injuries to the common carotidartery overall mortality and stroke rates were 17% and 28%,respectively. Patients presenting with coma or shock had aparticularly poor prognosis (50% and 41% mortality,

Fig. 2 Brain computed tomography showed evidence of rightbrain infarction with edema and left brain hemorrhage (arrow).

841.e4 Case Report

respectively) [5]. The outcome after carotid artery injury isinfluenced by many factors, including the mechanism ofinjury, the location and extent of carotid injury, the presenceof associated injuries, prehospital and ED management, thepatient's age and comorbid conditions, and the time todefinitive management [6].

Due to the rare injury and its poor prognosis, thediagnosis and management of penetrating injuries to thecervical carotid arteries continue to be controversial issues.These include the choice of diagnostic techniques, acutemanagement of the airway, operative exposure andmanagement, and the role of endovascular stenting in themodern era [7]. There are several main controversial issuesthat complicate the management of the transection ofcarotid artery intervention in our patient. The contamina-tion of the wound may cause infection and may finallycause the failure of the anastomosis of the artery. Thelower blood pressure during preoperation and postopera-tion despite aggressive resuscitation may result in dis-seminated intravascular coagulation, which may causemassive bleeding during operation which cannot becontrolled by surgical intervention. The uncertainty of thebrain damage after resuscitation puts in questionqqregarding the repair of the artery. Finally, ligation ofall injury arteries and veins with repair of the laryngealinjury was performed in this patient. Unfortunately, theright brain infarction with swelling finally caused centralfailure and death.

It is very difficult to reach a consensus of managementin this kind of patient due to the different traumamechanisms and patterns of injuries. Patients withpenetrating cervical wounds, preoperative neurologicdeficits, and immediate transport to the trauma centermay receive repair rather than ligation of the injuredcarotid artery. However, when the patient is truly comatosewith a Glasgow Coma Scale (GCS) score b8, anunsatisfactory neurologic outcome is likely with eitherarterial repair or ligation. Injuries to the extracranialinternal carotid artery in cervical zone III (above the angleof the mandible) may require innovative approaches tocontrol hemorrhage and then maintain flow to the

ipsilateral cerebral cortex [7]. du Toit et al reported thatqqthe presence of hypovolemic shock, internal carotid arteryinjury, complete vessel transection, and arterial ligation areassociated with unfavorable outcomes. Penetrating injuryto the brachiocephalic, common carotid, or internal carotidartery should be repaired rather than ligated whentechnically possible. Subsequent ischemic or hemorrhagiccerebral infarction is unpredictable, but the overalloutcome is superior to that with ligation of the injuredartery [8]. Teehan et al also reported on 1316 patients withno deficit, and patients with preoperative deficits didsignificantly better after repair as compared with afterligation. In comatose patients, however, management didnot affect the outcome. They concluded that carotidarterial injuries should be repaired in patients with normalneurologic evaluation and focal preoperative neurologicdeficits and in patients with GCS N9, and they also foundthat comatose patients with GCS b8 do poorly regardlessof management. The GCS provides an objective stratifica-tion of patients with altered state of consciousness whomay benefit from repair of carotid arterial injuries [9].Thal et al preoperatively classified patients into those withno neurologic symptoms, mild neurologic deficit, andsevere neurologic deficit. Only 1 of 6 patients with a milddeficit developed a stroke. In patients with severeneurologic deficit, the authors proposed performing anintraoperative arteriogram to assess distal cerebral bloodflow. If there was no flow, then the risk of conversion to ahemorrhagic infarct would theoretically be high andligation was recommended [10]. Therefore, there is stillcontroversy regarding the management of comatosepatients with ligation, and the long-term outcome andpatency rates after penetrating carotid artery injuriesremain unknown.

Our patients had internal and external carotid arterytotal transection, preoperative neurologic deficits, andimmediate transport to our ED. The resuscitation anddamage control were successful in ED after cardiopul-monary resuscitation, and bleeding was stopped by vesselclamping with forceps. Surgical intervention with ligationof internal carotid artery caused brain infarction, however,and this resulted in death, although his vital signs andpupils reflex were regained after surgical intervention andaggressive resuscitation in trauma ICU. In the patient withhypovolemic shock and GSC b8, management withdamage control should be reserved in the ED. Controversymay remain regarding the outcome of long-term neurologicdeficit after operation, but the outcome of the patient couldnot predicted before operation and should not be a reasonnot to repair the internal carotid artery. If a patient's vitalsigns can be restored, repair of the artery should beconsidered in the patient despite comatose status. There-fore, repair of the internal carotid artery in the selectivecomatose patient regaining vital signs after resuscitationand damage control in ED may be a more effectivetreatment than ligation.

841.e5Case Report

Hsing-Lin Lin MDYen-Ko Lin MD

Liang-Chi Kuo MDWei-Che Lee MD

Chao-Wen Chen MDDepartment of Trauma

Kaohsiung Medical University HospitalKaohsiung Medical University

Kaohsiung 807, TaiwanDepartment of Emergency Medicine

Kaohsiung Medical University HospitalKaohsiung Medical University

Kaohsiung 807, TaiwanE-mail address: p620822@yahoo.com.tw

Jiun-Nong Lin MDDivision of Infectious Diseases

Department of Internal MedicineE-Da Hospital/I-Shou University

Kaoshsiung, Taiwan

doi:10.1016/j.ajem.2008.01.041

References

[1] Demetriades D, Asensio JA, Velmahos G, et al. Complex problems inpenetrating neck trauma. Surg Clin North Am 1996;76:661-83.

[2] Thompson EC, Porter JM, Fernandez LG. Penetrating neck trauma: anoverview of management. J Oral Maxillofac Surg 2002;60:918-23.

[3] Feliciano DV, Bitondo CG, Mattox KL, et al. Civilian trauma in the1980s. A 1-year experience with 456 vascular and cardiac injuries.Ann Surg 1984;199:717-24.

[4] Mattox KL, Feliciano DV, Burch J, et al. Five thousand seven hundredsixty cardiovascular injuries in 4459 patients. Epidemiologic evolution1958 to 1987. Ann Surg 1989;209:698-705 [discussion 6-7].

[5] Ramadan F, Rutledge R, Oller D, et al. Carotid artery trauma: a reviewof contemporary trauma center experiences. J Vasc Surg 1995;21:46-55 [discussion -6].

[6] Demetriades D, Salim A, Brown C, et al. Neck injuries. Curr ProblSurg 2007;44:13-85.

[7] Feliciano DV. Management of penetrating injuries to carotid artery.World J Surg 2001;25:1028-35.

[8] du Toit DF, van Schalkwyk GD, Wadee SA, et al. Neurologic outcomeafter penetrating extracranial arterial trauma. J Vasc Surg 2003;38:257-62.

[9] Teehan EP, Padberg Jr FT, Thompson PN, et al. Carotid arterial trauma:assessment with the Glasgow Coma Scale (GCS) as a guide to surgicalmanagement. Cardiovasc Surg 1997;5:196-200.

[10] Thal ER, Snyder III WH, Hays RJ, et al. Management of carotid arteryinjuries. Surgery 1974;76:955-62.