Epidural Bleed with a Blunt Carotid Injury
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Transcript of Epidural Bleed with a Blunt Carotid Injury
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R. Todd Maxson, M.D.Trauma Medical Director
John Recicar, RNNursing Director Trauma CenterArkansas Childrens HospitalEpidural Bleed with a Blunt Carotid Injury
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16 year old female previously healthy, high speed rollover
Combative on scene and not moving left side
Intubated on Scene
Rapid transport to Level III TCPre-hospital
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Evaluation at OSH
To OR for evacuation of Epidural
Specialized transport team requestedInitial Hospital
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Team met patient in PACU
Optimized ventilation
Started a Transfusion
Returned to ACHTransport
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Direct admit to PICU
Involved Pediatric Surgery, CCM, Neurosurgery and Vascular Surgery
MRI / MRA done to evaluate brain injury and carotids with non resolved left sided discrepancy in movement
Tertiary Center
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Pulmonary contusions
Epidural with a shift
Carotid dissection with pseudoaneurysm
Occipital condyle fractureInjuries
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MRA C-Spine**
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Quickly extubated and transferred out of ICU
Duplex ultrasound unable to visualize lesion
Aspirin for anti-platelet effect followed by TEG
Lovenox at 60 mg BID for prevention of thrombin conversion with anti Xa level
Tertiary Center
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Admitted to Rehab service on day 4 with discharge on day
Continued on Warfarin
Ultrasound study no change in lesion
Follow up with ultrasounds and Vascular SurgeryTertiary Care
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Demonstrates all phases of hemostasisInitial fibrin formationFibrin-platelet plug constructionClot lysis
Identifies imbalances in the hemostatic system Risk of bleedingRisk of thrombotic event
Allows for individualization of component replacementWhy use TEG
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Remaining QuestionsWhen and How to screen for carotid injuryWhat is the appropriate early treatmentTEG use and level of inhibitionDefinitive treatmentStentLong term anticoagulation - ?**
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Should the transport team fully optimize before leaving?Yes to prevent hypotension and hypoxia following TBI Maybe depends on how sick the child is or if a critical intervention is neededNo doesnt make a difference**
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What do routine lab test of anticoagulation (PT, APTT) lack that TEG provides?
Ignore altered thrombin generationIgnore cellular elementsIgnore overall clot structure All of the above**