Traumatic Vascular Injury

Punctured

Step 1: View clinicals

A 28-year-old male bicyclist is brought to the emergency department about 30 minutes after he was hit by a car. In the field, he was found to be unconscious with a Glasgow coma score (GCS) of 6, and subsequently intubated. He also had an open injury of the right leg. The affected limb was immobilized with a posterior splint. Focused assessment with sonography for trauma (FAST) is negative for fluid in all four windows, while chest and pelvic x-rays are negative for acute bony injuries. However, x-rays of the right lower extremity reveal a tibia-fibula fracture.


Step 2: Order all relevant investigations

Contrast CT Chest + Abdomen

There is an injury to the proximal descending aorta, with intimal flap formation, and an associated pseudoaneurysm.

CT Angiogram

There is an aortic intimal flap with a pseudoaneurysm 2 cm distal to the take-off of the left subclavian artery from the aortic arch, with disruption of the medial wall of the descending thoracic aorta.

Coagulation studies

PT: 12.7 sec (11-13) INR: 1.0 (0.9-1.1) APTT: 31.7 s (30-40)

Transesophageal Echocardiogram

You realize that performing a transesophageal echocardiogram would waste valuable time.


Step 3: Select appropriate management

Aggressive IV fluid therapy
IV Nicardipine
Admission to the ICU
Endovascular aneurysm repair


Score: ★★☆