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American Journal of Emergency Medicine (2008) 26, 841.e3841.

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Case Report
Damage control in the transection of carotid arterya case report Abstract Transection of the carotid artery is very rare in Taiwan owing to tight gun control. Most carotid artery injuries are caused by penetration wounds as a result of stabbing or shooting. The total transection of internal and external common arteries is very rarely encountered, and most surgeons lack experience of this intervention. We present a very rare patient who had his right neck cut caused by a flying piece of sheet metal during a typhoon. The case was sent to our emergency department without any vital signs. Intubation was performed into the perforation of larynx with aggressive resuscitation. The patient regained his heart rate and blood pressure after several minutes of cardiopulmonary resuscitation. Then he was sent to operating room, where tracheostomy was performed and bleeding was controlled by ligation of all bleeding arteries including internal and external carotid arteries. Two days later, the patient died, however. We reviewed the literatures and discussed the case. A 28-year-old male patient who has been injured during a 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 could not be measured. Clinically, he presented poor peripheral perfusion with pale, cool extremities, and oliguria. His right neck had been cut by a flying sheet metal and had been compressed by gauzes with elastic bandage by the emergency medical technicians. Cardiopulmonary resuscitation was performed immediately with aggressive resuscitation after direct insertion of endotracheal tube into the perforation of larynx. After several minutes, his heart started beating and blood pressure was elevated. During exploration of the wound to his neck, a life-threatening transection injury above the bifida of the common carotid artery was found with mass active hemorrhage (Fig. 1). To control the bleeding, the trauma surgeon clamped the 2 ends of external and internal carotid artery with other small active bleeding points by forceps. The patient was immediately transferred to the operating room for the vascular and larynx repair.
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Fig. 1 The neck wound extended from zones I to II with internal and external carotid transection (white arrows) combined with other vessel injuries and laryngeal perforation.

In the operating room, tracheostomy was performed, and the clamped arteries were immediately ligated due to active leaking from the wound and relative hypotension of the patient. Laryngeal perforation was repaired, and all intervention was done within 1 hour. The patient was sent to intensive care unit (ICU) for further management. In ICU, the patient's blood pressure elevated after resuscitation, and his bilateral pupils also had light reflex in the first 12 hours. The wound leaked extensively if the blood pressure was elevated. Then, his right pupil dilated, and brain computed tomography showed right brain edema with left hemisphere hemorrhage (Fig. 2). Two days after, his blood pressure dropped, and he died as a result of central failure [1,2]. Injury to the artery distal to the bifida of common carotid artery is a rare event, with a poor prognosis and high mortality. Penetrating injuries to the carotid and vertebral arteries account for only 3% and 0.5%, respectively, of arterial injuries treated in other trauma centers [3,4]. Ramadan et al reported that injuries to the common carotid artery overall mortality and stroke rates were 17% and 28%, respectively. Patients presenting with coma or shock had a particularly poor prognosis (50% and 41% mortality,

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Case Report ipsilateral cerebral cortex [7]. du Toit et al reported thatqq the presence of hypovolemic shock, internal carotid artery injury, complete vessel transection, and arterial ligation are associated with unfavorable outcomes. Penetrating injury to the brachiocephalic, common carotid, or internal carotid artery should be repaired rather than ligated when technically possible. Subsequent ischemic or hemorrhagic cerebral infarction is unpredictable, but the overall outcome is superior to that with ligation of the injured artery [8]. Teehan et al also reported on 1316 patients with no deficit, and patients with preoperative deficits did significantly better after repair as compared with after ligation. In comatose patients, however, management did not affect the outcome. They concluded that carotid arterial injuries should be repaired in patients with normal neurologic evaluation and focal preoperative neurologic deficits and in patients with GCS N9, and they also found that comatose patients with GCS b8 do poorly regardless of management. The GCS provides an objective stratification of patients with altered state of consciousness who may benefit from repair of carotid arterial injuries [9]. Thal et al preoperatively classified patients into those with no neurologic symptoms, mild neurologic deficit, and severe neurologic deficit. Only 1 of 6 patients with a mild deficit developed a stroke. In patients with severe neurologic deficit, the authors proposed performing an intraoperative arteriogram to assess distal cerebral blood flow. If there was no flow, then the risk of conversion to a hemorrhagic infarct would theoretically be high and ligation was recommended [10]. Therefore, there is still controversy regarding the management of comatose patients with ligation, and the long-term outcome and patency rates after penetrating carotid artery injuries remain unknown. Our patients had internal and external carotid artery total transection, preoperative neurologic deficits, and immediate transport to our ED. The resuscitation and damage control were successful in ED after cardiopulmonary resuscitation, and bleeding was stopped by vessel clamping with forceps. Surgical intervention with ligation of internal carotid artery caused brain infarction, however, and this resulted in death, although his vital signs and pupils reflex were regained after surgical intervention and aggressive resuscitation in trauma ICU. In the patient with hypovolemic shock and GSC b8, management with damage control should be reserved in the ED. Controversy may remain regarding the outcome of long-term neurologic deficit after operation, but the outcome of the patient could not predicted before operation and should not be a reason not to repair the internal carotid artery. If a patient's vital signs can be restored, repair of the artery should be considered in the patient despite comatose status. Therefore, repair of the internal carotid artery in the selective comatose patient regaining vital signs after resuscitation and damage control in ED may be a more effective treatment than ligation.

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

respectively) [5]. The outcome after carotid artery injury is influenced by many factors, including the mechanism of injury, the location and extent of carotid injury, the presence of associated injuries, prehospital and ED management, the patient's age and comorbid conditions, and the time to definitive management [6]. Due to the rare injury and its poor prognosis, the diagnosis and management of penetrating injuries to the cervical carotid arteries continue to be controversial issues. These include the choice of diagnostic techniques, acute management of the airway, operative exposure and management, and the role of endovascular stenting in the modern era [7]. There are several main controversial issues that complicate the management of the transection of carotid artery intervention in our patient. The contamination of the wound may cause infection and may finally cause the failure of the anastomosis of the artery. The lower blood pressure during preoperation and postoperation despite aggressive resuscitation may result in disseminated intravascular coagulation, which may cause massive bleeding during operation which cannot be controlled by surgical intervention. The uncertainty of the brain damage after resuscitation puts in question qqregarding the repair of the artery. Finally, ligation of all injury arteries and veins with repair of the laryngeal injury was performed in this patient. Unfortunately, the right brain infarction with swelling finally caused central failure and death. It is very difficult to reach a consensus of management in this kind of patient due to the different trauma mechanisms and patterns of injuries. Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center may receive repair rather than ligation of the injured carotid artery. However, when the patient is truly comatose with a Glasgow Coma Scale (GCS) score b8, an unsatisfactory neurologic outcome is likely with either arterial repair or ligation. Injuries to the extracranial internal carotid artery in cervical zone III (above the angle of the mandible) may require innovative approaches to control hemorrhage and then maintain flow to the

Case Report Hsing-Lin Lin MD Yen-Ko Lin MD Liang-Chi Kuo MD Wei-Che Lee MD Chao-Wen Chen MD Department of Trauma Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung 807, Taiwan Department of Emergency Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung 807, Taiwan E-mail address: p620822@yahoo.com.tw Jiun-Nong Lin MD Division of Infectious Diseases Department of Internal Medicine E-Da Hospital/I-Shou University Kaoshsiung, Taiwan doi:10.1016/j.ajem.2008.01.041

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References
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