Research Article - (2020) Volume 5, Issue 1
1Surgeon, Trauma and Emergency surgeon, Colombia
2Cirujano, Breast Surgeon, Colombia
Received Date: February 25, 2020 Accepted Date: March 26, 2020 Published Date: April 2, 2020
Citation: Quintero A (2020) Characterization of Patients with Carotid Artery Trauma in a 4th Level Hospital in a Ten Years Period. Trauma Acute Care Vol.5 No.1: 3 DOI: 10.36648.2476-2105.5.1.77
Copyright: © 2020 Quintero A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Carotid trauma is a well-known entity with severe morbidity and high rates of mortality. Due to its low frequency of appearance an interdisciplinary effort is needed to get at diagnosis. We reviewed 946 clinical histories with a diagnosis of cervical trauma, cervical fracture, vascular trauma of the neck and craniofacial trauma looking for Denver´s risk factors for carotid trauma in a 10 years period in a 4th level Colombian hospital. Overall, 36 patients where found, most of them Young men. The most frequent trauma mechanism was violence-related, no blunt carotid trauma was diagnosed in this study, none received stroke prophylactic treatment, although no stroke was reported. Our study describes a population of patients with open cervical trauma despite the inclusion of blunt vascular trauma criteria showing that there is a lack in the approach and treatment of these patients in the emergency room. Actually, we are aiming for a complete treatment guide that leads us bring optimal diagnosis and treatment.
Carotid Trauma; Cervical trauma; Stroke
In the spectrum of traumatic entities, cervical trauma is one of the less common ranging from 1 to 2.6% of all blunt traumas. Skull base fractures, cervical, facial and spinal fractures in addition to chest trauma have been identified as associated risk factors for cervical injuries [6]. Approximately 1% of patients with major trauma have cerebrovascular trauma, this lesions are more common in patients with severity scores for trauma higher than 16 points and those who require more than 24 hours in hospital [9].
Carotid blunt trauma becomes important in suspicion and early diagnosis due to his association with high rates of ischemic stroke (60%), severe neurological sequelae and high mortality (19- 43%), these patients are asymptomatic initially in 66-73% and may have stroke symptoms even 31 days after the trauma event [1-3]. Denver an Memphis diagnostic criteria for carotid trauma where evaluated in a 2012 study published in Jama, over a 14 years period between 1997 and 2010 showing that patients with specific trauma mechanism where asymptomatic and of them 20% weren’t identified using actual tamisation test [7,8].
Preston Miller and cols in 2002, showed that no invasive diagnostic test like angiotomography or cervical magnetic resonance aren’t accurate enough as screening test for carotid blunt trauma using a efficiency evaluation comparing with angiography [11,12]. Internal carotid artery trauma has been associated with poor prognosis and requires early management. Improvements in diagnostic images have lead to a prompt diagnosis and better outcomes, there is a growing consensus about the early use of antithrombotic therapy. Most of these interventions include endovascular procedures. Although long-term follow-up studies are lacking, these treatment techniques have demonstrated safety and efficacy in reducing neurological complications in both internal and external carotid trauma.
Despite the consensus about the need for antithrombotic or antiplatelet preventive therapy for stroke after carotid trauma, there is not a generally accepted management guide on this topic. The objective of this work is to describe our population and outcomes for patients with carotid trauma admitted to the emergency room of a single 4 level Hospital in Colombia.
For this purpose, a descriptive retrospective study was designed on a single cohort corresponding to the population over 13 years old admitted to the emergency room of the Hernando Moncaleano Perdomo Hospital from Neiva, with cervical and carotid trauma in 10 years, between January 2007 and August 2017. Once the database was reviewed using the manual of diagnostic codes of the International Classification of Diseases in its edition 10 (ICD10), 946 patients were collected, after the analysis, 36 patients were identified.
The average age was 29 years, with male prevalence with 33 of 36 patients (91.6%). None of the patients admitted into the study had previously known cardiovascular disease, diabetes mellitus, high blood pressure or chronic kidney disease. Six patients of 36 (16.6%) had previous hospitalizations due to the use of psychotropic drugs.
The most frequent mechanism of trauma was stab wounds with [19,5] of 36 patients (54.3%), followed by gunshot wounds (34.3%), motorcycle accidents as drivers (5.7%) and two wounds caused by fragmentation grenades (5.7%) Table 1.
| n [%] | |
| Gun Shot | 12 [34.3] |
| Stab wounds | 19 [54.3] |
| Transit | 2 [5.7] |
| Other | 2 [5.7] |
| VITAL SIGNS | |
| Sistolic blood pressure | 67 [52-78] |
| Diastolic blood pressure | 110 [90-130] |
| Respiratory rate | 20” [18-25] |
| Heart rate | 91” [80-115] |
Table 1: Trauma mechanism
Vital signs at admission recorded show systolic arterial tensions average 110mm Hg with narrow ranges of presentation that vary from 90-130 mm Hg, diastolic blood pressure was presented on average with a value of 63 mm Hg, with variations ranging from 52-78 mm Hg.
Other vital variables such as heart rate and respiratory rate were found in average values of 91 beats per minute and 20 breaths per minute with values ranging from 80-115 beats and 16-25 breaths per minute respectively. None had a Glasgow coma scale below 15/15. None of 36 patients required transfusions.
According to anatomical neck areas, traumatic wounds occurred more frequently in zone II (63%), followed by zone I (26.6%) and finally zone III (10%), predominant right laterality (60%) Figure 1.
Figure 1: Wound locations.
Injuries associated with penetrating trauma were found in 21 patients. Upper airway injury was the most common, present in 11 patients of 21 (52%), followed by lung lesions (28.5%), esophagus and brachial plexus (9.5%). AIS (Abbreviated Injury Scale) evaluation showed that severe AIS 4 lesions were found in 13 of 36 patients (36.1%), AIS 3 was found in 22.2%, AIS 5 in 27.7%, AIS 2 lesions only 8.33%, no lesions described as AIS 1 or AIS 6 were found. Observed mortality was 5.7%.
About Denver criteria for carotid artery trauma, we found that the most frequently described finding was the presence of expansive hematoma in 12 of 36 patients (34.3%), followed by cervical hematoma (26.6%), pulsatile bleeding (22.7%), cervical fracture (5.7%), craniofacial fracture le Fort II-III (2.9%) and hanging trauma (2.9%). 55.5% had none of the Denver criteria, 8.33% had 4 criteria, 13.8% had 3 criteria, 5.5% 2 criteria and 19.4% had 1 criteria.
Once patients were admitted to the emergency room, 72.2% went for cervical exploration surgery, 27.7% (10 patients) received medical follow-up. Of these 10 patients [4] did not require any type of surgical intervention, [3] required delayed surgery after imaging studies. None required reintervention.
About imaging studies, 7 chest radiographs (20%) were obtainded, right pneumothorax was found in 57.1%, left pneumothorax in 14.2 and bilateral pneumothorax in 14.2%. Right hemothorax in 42.8%, left hemothorax and bilateral in 14.2%. Vessel Neck ultrasound was performed in 5 of 36 patients (13.8%), 80% were reported as normal. Cervical angiotomography was performed in 8 patients (22.2%), with abnormal findings in 7 patients (87.5%). No arteriography was performed, neither endovascular management was needed for any of them.
In-hospital management was divided for this study into three areas: emergency room, hospitalization, and Intensive Care Unit obtaining the following results. Only 11.1% remained in the emergency room and observation for more than one day, with an average stay of 2.7 days each. 63.8% remained as inpatient for more than one day, with an average hospitalization time of 9.2 days. 10 patients (27.7%) required treatment in ICU with an average hospitalization time of 5 days [21]. Regarding antithrombotic or antiplatelet therapy, we found that only 16.6% received prophylactic antithrombotic therapy related to a long hospital stay in ICU. No stroke was identified in this study population [14-16].
Cervical blunt trauma is a low-frequency finding in the emergency room, being 1 to 2.6% of all blunt trauma, our experience for this injury rate is 3.8%. Clinical awareness of possible internal carotid artery injury and early diagnosis become important because it is associated with high rates of ischemic stroke (60%) and severe neurological sequelae and mortality (19-43%). Complications can be significantly reduced with appropriate diagnosis and early treatment [1,2,3,10].
Internal carotid artery injuries have a poor prognosis and require adecuate treatment. There is a growing consensus about the need for early use of antithrombotic therapy. Fusco and Harrigan in 2011 found that Denver criteria were useful to define the need for cerebrovascular imaging studies in 4.8% of a total of 249 patients, of which 18% had internal carotid blunt trauma.
The presence of one criterion predicted the presence of a carotid lesion in 33-48% of patients, two criteria increase the probability of about 56-74%, three criteria 80-88% and all criteria 93%. Our study, when applying the same criteria, we found that 19.4% of the patients had more than 3 positive criteria for carotid artery blunt trauma, 5.5% had 2 criteria and 19.4% had only one criterion.
However, none underwent arteriography for diagnosis or endovascular management was offered because this diagnosis was not suspected. There is no consensus about medical management with anticoagulation or antiplatelet therapy for stroke prophylaxis. There are multiple non-randomized studies and case reports where the application of systemic anticoagulation improves prognosis in patients with neurological symptoms and prevents stroke in asymptomatic patients [12,13].
Studies report the same effectiveness between systemic heparinization and antiplatelet therapy (clopidogrel or Acetylsalicylic acid) stroke prophylaxis [17-19]. Only 16.6% of our patients received thromboprophylaxis treatment with low molecular weight heparins.
The population that most often enlarges trauma statistics are young males, with trauma mechanisms related to urban violence and conflict. Our hospital receives a great number of patients with trauma mechanisms that determine identifiable risk factors for carotid blunt trauma. This study identified 946 patients with suspicious for cervical blunt trauma and none of them had any vascular imaging studies to rule out carotid blunt trauma. Carotid trauma was made and vascular studies were performed in patients with open neck trauma and cervical vascular injury that required some type of surgical intervention [20,22,23].
Patients had high scores of trauma severity assessment (AIS) with scores equal to or greater than 3 in 86% of patients. These injuries were related to injury to neighboring structures that reach almost 60%. Although more studies with strong evidence and recommendations are needed for antiaggregant or antithrombotic prophylaxis schemes, high morbidity and mortality rate related to blunt and open carotid trauma is a fact, no stroke events were described on this study. Only a few patients received antithrombotic prophylaxis with low molecular weight heparins. A large interdisciplinary effort is required to identify patients with risk factors for carotid blunt trauma.
