punjabiMD

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A 65-year-old man is brought into the ED with a gunshot wound to the neck. His blood pressure is 80/50 mmHg. The patient undergoes rapid resuscitation and is brought immediately to the OR, where a carotid artery injury is found in zone II. The patient has no internal carotid flow; just before surgery, his neurological status deteriorates, and he becomes unresponsive. The operative management should be which of the following?

A. immediate intravascular bypass shunt
B. ligation of the internal carotid artery
C. primary anastomosis
D. interposition saphenous vein graft
E. patch vein graft
 

Celiac Plexus

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sardarg89 said:
A 65-year-old man is brought into the ED with a gunshot wound to the neck. His blood pressure is 80/50 mmHg. The patient undergoes rapid resuscitation and is brought immediately to the OR, where a carotid artery injury is found in zone II. The patient has no internal carotid flow; just before surgery, his neurological status deteriorates, and he becomes unresponsive. The operative management should be which of the following?

A. immediate intravascular bypass shunt
B. ligation of the internal carotid artery
C. primary anastomosis
D. interposition saphenous vein graft
E. patch vein graft
ok what the hell, i'll give it a shot. choice C is a no-go. primary anastomosis is unlikely to be possible considering his carotid is missing a segment secondary to a bullet wound.

choices D and E would be appropriate for a stable patient requiring revascularization secondary to occlusive disease. not good choices in this scenario.

choice A would be a good option if it could be done very quickly. but since this guy is going down hard, i wouldn't do this operation.

choice B looks to be the best choice. ideally i'd like to know that his vertebrals and the other ica are not compromised... since we can't know this without shooting an angio, and we can't shoot an angio on this patient, and the guy is obviously trying to die, i choose to take the risk that he has adequate collateral flow. I would ligate the carotid, and volume resuscitate the guy as fast as possible... and say a few hail marys...
 

DO_Surgeon

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sardarg89 said:
A 65-year-old man is brought into the ED with a gunshot wound to the neck. His blood pressure is 80/50 mmHg. The patient undergoes rapid resuscitation and is brought immediately to the OR, where a carotid artery injury is found in zone II. The patient has no internal carotid flow; just before surgery, his neurological status deteriorates, and he becomes unresponsive. The operative management should be which of the following?

A. immediate intravascular bypass shunt
B. ligation of the internal carotid artery
C. primary anastomosis
D. interposition saphenous vein graft
E. patch vein graft
There is a similar case on trauma.org. It was repaired with a patch vein graft.
 

mcwmark

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I agree with the celiac plexus:


A. immediate intravascular bypass shunt
B. ligation of the internal carotid artery
C. primary anastomosis
D. interposition saphenous vein graft
E. patch vein graft


I think the key points are:
1. Patient is dying
2. Patient appears to have had a CVA prior to the OR
3. No ICA flow

Goals should be:
1. Rescusitate, repair and get out of OR as quickly as possible
2. No ICA flow + clinical symptoms = likely patient will have massive ischemic event, repair of flow may mean reperfusion injury or hemorrhagic stroke
3. If the patient had been stable and not had a stroke prior to the OR, I'd go with E>C. This case should be B.