A 45-year-old man presented to the emergency department (ED) as a trauma patient after a motor vehicle collision. He was a restrained passenger of a single-vehicle accident. The Glasgow Coma Scale (GCS) score was assessed as 9 in the field. The emergency medical services team was unable to obtain IV access or intubate before arrival in the ED. An intraosseous line was placed in the right humerus for access.
On arrival to the ED, the patient’s blood pressure was 111/85 mm Hg, heart rate was 124 beats per minute, and pulse oximetry was 100% on room air. Physical examination was notable for morbid obesity, right facial droop, seat belt sign to the left neck and chest and lower abdomen, and decreased breath sounds in the right chest. The GCS score on arrival to the ED was 10 (4E/5M/1Va). The patient was intubated in the ED by the ED attending, who also placed an arterial line in the right femoral artery and a right subclavian central line. A chest tube was placed in the right thorax, and imaging scans and laboratory tests were performed.
Lab results were significant for mild leukocytosis (20.3 × 109/L), hyponatremia (130 mmol), elevated creatinine (2.00 mg/dL), severe hyperglycemia (679 mg/dL), an anion gap of 17, hemoglobin A1c of 12.7% and an elevated lactate of 10.1 mmol. In addition, the patient had metabolic acidosis with arterial blood gas scores of pH 7.25, CO2 39, PaO2 332 mm Hg and HCO317 mEq/L, with a base excess of negative 9.9 mmol. Of note, his hemoglobin was normal at 13.4 g/dL.
The patient was brought to the operating room emergently with the trauma team and the vascular surgeon. On arrival, he was on a norepinephrine drip at 12 mcg per minute and an insulin drip at 12 units per hour. His endotracheal tube was connected to the ventilator and he was induced with sevoflurane. After induction, he was paralyzed with vecuronium. His right chest tube was placed to suction. The surgeons prepped and draped, and began surgical correction of the patient’s left carotid artery injury. The patient appeared hypovolemic, as indicated by hypotension, low urine output and increased stroke volume variation. He received a total of 8 L of crystalloids during the 4.5-hour case and was weaned off the norepinephrine drip. Blood glucose level decreased slowly throughout the case, from 552 mg/dL at the beginning to 251 prior to transport to the ICU, and the anion gap closed. A right radial arterial line was placed by anesthesia intraoperatively after the surgery began, and the right femoral arterial line was discontinued postoperatively. The patient, still intubated, was transported to the ICU.
This patient had a left common carotid artery injury caused by a seat belt restraint in a motor vehicle accident. His left common carotid was completely transected with thrombosis; the carotid was held together only by the adventitia. The wall of the carotid artery also was bruised all the way to the thoracic outlet. The seat belt not only injured the left common carotid, but also lacerated the patient’s sternocleidomastoid muscle. The left common carotid artery and sternocleidomastoid injuries were surgically corrected. The patient also had an acute kidney injury and diabetic ketoacidosis, which were treated.
This case illustrates the importance of physical examination findings. The patient had a very prominent seat belt sign across his left neck and a right facial droop. Both of these signs led to obtaining a CT angiogram of the neck vasculature and to quick identification and surgical correction of the traumatic left common carotid artery injury.