R. Todd Maxson, M.D. Trauma Medical Director John Recicar, RN Nursing Director Trauma Center Arkansas Children’s Hospital Epidural Bleed with a Blunt Carotid Injury
Feb 22, 2016
R. Todd Maxson, M.D.Trauma Medical Director
John Recicar, RNNursing Director Trauma CenterArkansas Childrens HospitalEpidural Bleed with a Blunt Carotid Injury
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
Evaluation at OSH
To OR for evacuation of Epidural
Specialized transport team requestedInitial Hospital
Team met patient in PACU
Optimized ventilation
Started a Transfusion
Returned to ACHTransport
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
Pulmonary contusions
Epidural with a shift
Carotid dissection with pseudoaneurysm
Occipital condyle fractureInjuries
MRA C-Spine**
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
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
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
Remaining QuestionsWhen and How to screen for carotid injuryWhat is the appropriate early treatmentTEG use and level of inhibitionDefinitive treatmentStentLong term anticoagulation - ?**
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**
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**