June case: (Week 8 day 4) Could this be traumatic carotid dissection? What now ??
Back in resus with our polytauma patient that has deteriorated. You are a bit baffled by it all. A sudden unexpected dramatic change in his condition has lead you to believe what you are seeing is a patient that is having a stroke right there in front of you.
A stroke? Really? Scenarios of “what came first, was it the chicken or the egg” runs trough your mind: Can it be that the patient had a transient ischaemic attack and then crashed? Is it coincidental? Are these two separate pathologies? Or a drug effect , or a bleed?
Regardless of the cause for this, in true anaesthetist style you decide it is more important to support than diagnose and decide to give that patient an anaesthetic, secure the airway, control ventilation and then have a team hunt for the diagnosis to explain how a quite boring Saturday afternoon has unraveled into this enigma!
- How would you anaesthetise this person? What drugs would you use?
The question remain: What is going on? The answer doesn’t seem that clear to your slightly overwhelmed and tired brain at the moment. There is no external signs of a head injury in this patient and the plain c-spine films didn’t show any cervical spine fractures. Never ever have you seen this before, so surely it must be rare or not even a thing. Then one of the nurses asks a question that sort of just hangs in the air: “Surely a whiplash injury can’t give you this neurology? Or a blow to the neck maybe?
Slowly you baffled mind refocuses on the neck area. “Can it?” You wander. “Can a rapid deceleration and rotation of the neck put enough stress on the vessels in the neck to cause this? And add to this a seatbelt..”
With your patient now anaesthetised, the team decide further imaging is required.
You decide it might be some sort of vascular neck injury affecting cerebral perfusion.
- What imaging will confirm your suspicions?
- How do traumatic carotid dissections classically present?
- What is the treatment for traumatic carotid dissections?
- What are important consideration in polytrauma patients with traumatic carotid dissections?
Put your thinking caps on. Google or bing or consult your textbooks. Try and share helpful links if you find any and remember to use the hashtag #gasclass in your tweets so that everyone can follow it.
Case conclusion tomorrow ( or in my case, later today, since the sun is just rising on my theatre night shift).
Be part of the conversation.