Monday, December 27, 2004

Tales From the Trauma Service III.....
Another case picked up by my partner.
20-ish year old stabbed in the left neck in zone I. For your information here are the anatomical division of the neck described by Monson in 1969:

The blue lines indicate the location of the wound. There was active bleeding and a bruit and thrill over the neck so the patient was taken to angiogram which revealed a common carotid to jugular fistula. (images poor). The neck was explored and packed as no stent-graft was readily available. One became available the next day:

The black squiggly lines in the upper right are from packing left in place from the exploration. Attempts were made to remove the packing yet again, but bleeding continued. The patient was then taken to the OR again for possible sternotomy for repair of what was thought to be the inominate vein. Another attempt would be made for an endovascular repair. The patient was found to have thrombosed his internal jugular vein on that side with a thrombosis in his axillary vein as well. The axillary DVT was thrombolysed with an Angiojet. The following images are from the endovascular repair. I apologize in advance for the quality:

The yellow line represents the subclavian vein, the green lines represent the extravasated contrast in the injured area.

The yellow lines indicate the stent in situ. Importantly there is no further leak of contrast.

Good flow through the stent. Here is a better image:

He was extubated on postop day 3, and is progressing.


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