2024 FSA Podium and Poster Abstracts
P017: ANESTHETIC MANAGEMENT OF TRAUMA PATIENT IN CARDIAC ARREST AND CAROTID ARTERY DISSECTION
Madina AKhmetkaliyeva, MD1; Skylar R Harmon2; Michael Decker, MD3; 1HCA Florida Kendall Hospital; 2Nova Southeastern University, Dr. Kiran C Patel College of Allopathic Medicine; 3HCA Florida Aventura Hospital
Introduction: Carotid artery dissection introduces a cascade of challenges during anesthesia, from an increased risk of stroke to hemodynamic shifts, vascular compromise, and intricate monitoring dilemmas. This case report examines the intricate balance between anesthesia and critical care in the face of neck trauma of the great vessels and nerves particularly in high acuity instances like cardiac arrest.
Methods: A 16-year-old male with no PMHx arrived via EMS after being struck on a standstill motor scooter by an ambulance responding to an unrelated emergency. The collision resulted in a large laceration to the left lower neck with profuse bleeding. Unconscious with a GCS 3, the patient was intubated in the trauma bay. On arrival the patient was in cardiac arrest requiring CPR, a left thoracotomy, manual cardiac massage, and clamping of the descending thoracic aorta. Rushed to the OR for neck exploration, the patient received crystalloids, MTP, cryoprecipitate, epinephrine, bicarbonate, and infusion of TXA. Eventually in the operating theater MAP above 75 was achieved and the aortic clamp was removed. Sedation was maintained with Midazolam, Sevofurane and Fentanyl.
The major vessels of the neck were precautionarily ligated with thoracotomy closure, and JP drain placement. The patient exited the OR under remarkably improved stable hemodynamic status, paving the way for postoperative investigations.
CT angiography of the head and neck revealed left common carotid artery dissection with adequate ligation and collateral reconstitution. A chest CT disclosed bilateral pulmonary contusions with moderate left pneumothorax.
Results: Post-surgery, the patient remained on mechanical ventilation, transferred to the SICU. Sedation withdrawal revealed minimal movement in the right extremities with evidence of partial Horner’s Syndrome. Brain MRI disclosed a left globus pallidus infarction with a small hippocampal infarction. Guided by Neuro IR, initial goal SBPs of 160-180 with Levophed prn, while midodrine sustained MAPS 80-90s for collateral development. Successful extubation occurred on post-op day 4. Inpatient recovery was marked by significant milestones and interventions with IVC filter placement and removal, ambulation with a walking device, and weight bearing as tolerated. Day 22 the patient was discharged with significantly improved right sided neurological deficits.
Discussion/Conclusion: This case illuminates the intersection of trauma, critical care, and anesthesia in the intricate management of complex neurovascular neck trauma. Carotid artery dissection thrusts anesthesia providers into a realm of heightened stroke risk and vascular compromise, demanding meticulous consideration and management through vigilant monitoring and precise hemodynamic resuscitation during head and neck procedures.