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Penetrating Neck Trauma Templeton 13 th Annual Symposium

Penetrating Neck Trauma Templeton 13 th Annual Symposium. Matthew Moront , MD-Trauma Medical Director Amy Pollich -Clinical Nurse St. Christopher’s Hospital for Children. DISCLOSURE. No relationships to disclose. THE PATIENT.

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Penetrating Neck Trauma Templeton 13 th Annual Symposium

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  1. Penetrating Neck TraumaTempleton 13th Annual Symposium Matthew Moront, MD-Trauma Medical Director Amy Pollich-Clinical Nurse St. Christopher’s Hospital for Children

  2. DISCLOSURE No relationships to disclose

  3. THE PATIENT • 3-year-old female carried into the emergency department at St. Christopher’s Hospital for Children by her mother • Gunshot wound to the left neck • Unresponsive • Extensive pre-hospital blood loss

  4. PRIMARY SURVEY Apneic, pulseless, PEA on ECG Estimated weight: 15 kg • A: Immediately intubated, 4.5 cuffed tube • B: Mechanical breath sounds, equal bilaterally • C: Chest compressions initiated, PIV/IO access, central access obtained, Patient received uncrossmatched O-negative blood • D: GCS 3T • E: No other injuries identified; Patient warmed in trauma bay with blankets, warming lights, Bair hugger

  5. What Would You Do Now? • Call It • Continue With Normal Saline Resuscitation • Initiate Transfusion with PRBC • Proceed to the OR

  6. RESUSCITATION • 2.5 units packed red blood cells (~50mL/kg) • 1.3 liters normal saline (~85mL/kg) • Epinephrine, atropine • Sodium bicarbonate, 2.5 ampules • Calcium chloride, 1 ampule • Nasogastric tube and foley catheter placed

  7. RESUSCITATION • Pulse regained 14 minutes after arrival • T 36.3º C, P 125, BP 73/31, 91% SaO2 • Pulsatile hemorrhage from left neck wound • Control obtained with digital pressure

  8. SECONDARY SURVEY • No additional injuries noted

  9. 5.2 143 125 8 218 7.8 76 3.0 8 0.36 16.5 iCa 0.61 PT 40.8 aPTT 107 Lactate 7.2 AST 47 ALT 27 Alk phos 35 Amylase 21 VBG: 6.91 / 61 / 19 / 12 / -21.3

  10. What Would You Do Now? • Proceed to OR for Exploration • Pack in the ED and hope it clots • Go to CT for Diagnostic Evaluation • Endovascular Repair

  11. DECISION ANALYSIS • Operative exploration • Unclear level of injury, distal arterial control likely not possible • Great concern for exsanguination with open operative exposure

  12. DECISION ANALYSIS • Endovascular repair • Advantages: • Identification of site of injury • Arterial repair with concurrent hemorrhage control • Challenges: • Never attempted at our facility • Neurointerventionalists: Adult physicians, off-site

  13. ENDOVASCULAR REPAIR • Left common carotid artery injury identified • Hemorrhage controlled with 6 mm x 16 mm covered stent • Platelets, FFP, bicarbonate given in catheterization lab • IV antibiotics given pre-procedure

  14. TIMELINE • 2210: Arrival to trauma bay • 2213: Intubated, PIV access attempted • 2217: IO access attempted • 2226: Central access obtained • 2235: Vital signs regained • 0105: Transported to cath lab • 0115: Procedure start • 0241: Procedure end • 0245: Transported to ICU

  15. HOSPITAL COURSE • Patient admitted to ICU post-procedure • T 37.0, P 122, BP 103/69, SaO2 100% • Cervical collar remained in place • CT head/cervical spine obtained

  16. What Do You Do Now? • Begin Heparin to Maintain PTT 40-60 sec • Proceed to OR for Stent Removal and Operative Repair • Remove Stent in Angio in 3-5 days • None of the Above

  17. HOSPITAL COURSE • Extubated 21-hours after presentation • Diet initiated on hospital day #3 • IV antibiotics continued for 7 days post-procedure • Abscess formed on right shoulder at bullet site • Drained in OR, bullet removed

  18. HOSPITAL COURSE • Discharged home post-procedure day #8, neurologically normal • Miami-J collar for C5 body fracture • ASA 81 mg every other day • Carotid duplex in 6 months

  19. FAMILY-CENTERED CARE • Healing Hurt People • Violence intervention program at St. Christopher’s Hospital for Children • Actively working with patient’s mother • Psychological therapy • Community college

  20. Would You Plan for Stent Removal? • Yes • No • Continue to Monitor

  21. ACKNOWLEGEMENTS • Dr. Marshall Schwartz, trauma attending • Dr. Robert Koenigsberg, interventional radiologist • Dr. Igor Mesia, interventional cardiologist • Dr. Christine Schlichting, intensivist • St. Christopher’s intensive care nursing staff • St. Christopher’s social work

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