Carotid artery penetrating trauma: Report of 4 cases and literature revision

Abstract

Introduction and importance

In penetrating neck trauma, carotid artery penetrating trauma is considered one of the most complicated injuries to treat. Active bleeding, large hematomas, and rapid occlusion of the airways make the surgical approach to controlling bleeding and repairing the vessel much more complex, constituting an essential clinical challenge to every surgeon.

Case presentation

We present 4 cases of patients with carotid artery penetrating trauma. Two patients were treated with endovascular therapy, one with surgery, and the fourth one treated conservatively. None of the patients had posterior neurological impairment.

Clinical discussion

Carotid artery penetrating trauma is uncommon yet is associated with high rates of mortality and neurological impairment. The common carotid artery is the most frequently injured, and gunshot wounds (GSW) are the most frequent trauma mechanism. Angiotomography (CTA) is the first-line exam for diagnosing these injuries. Treatment should be prompt and individualized and may include conservative techniques, endovascular therapy, and traditional surgical repair.

Conclusion

Carotid artery penetrating trauma is an uncommon but complex injury that requires a timely diagnosis and treatment to avoid potentially devastating consequences, particularly in hemodynamically unstable patients. Traditionally, the treatment strategies for these injuries used to be limited to vascular repair or ligation. However, endovascular therapy and conservative management are viable alternatives, which have become more and more useful in selected patients, allowing less invasive approaches with fewer morbidity and acceptable results.

Highlights

• •Carotid artery trauma penetrating trauma is infrequent; however, it is associated with high rates of neurological repercussions and mortality.
• •The common carotid artery is the most frequently injured vascular structure, followed by the internal carotid artery and the external carotid artery.
• •Gunshot wounds are the primary mechanism of lesions.
• •Computerized angiotomography (CTA) is the first-line exam for diagnosing these injuries.
• •Treatment strategies include surgical repair, endovascular therapy, and conservative management.

1. Introduction

Carotid artery penetrating injuries are infrequent and constitute a clinical challenge for surgeons due to the propensity to bleed actively, form expansive hematomas that can collapse the airways, or cause potentially devastating neurological sequelae associated with high morbidity and mortality rates [1].

Imaging testing and definitive treatment strategies depend on the hemodynamic stability of the patient and the presence of severe or mild signs of vascular injury. In unstable patients with severe signs of vascular injury, emergent surgical intervention is indicated. In patients with mild signs of vascular injury, and those with severe signs who are hemodynamically stable or transitory responders to resuscitation, diagnostic imaging is indicated and allows identification of the vascular injury's location, extension, and severity. According to these findings, an appropriate treatment could be determined: surgical repair, endovascular therapy, and, in well-selected cases, conservative management [2]. The following article is a description of four patients with penetrating cervical trauma and a carotid artery injury who were satisfactorily treated with different therapeutic approaches. This case series was written per the PROCESS 2023 criteria [3].

2. Case report 1

A male patient, 34 years old, arrives in the emergency department (ED) after suffering multiple Low-velocity gunshot wounds (GSW) in the neck and posterior left thorax about 40 min before admission. At the primary evaluation, vital signs were as follows: heart rate (HR): 110 beats per minute, respiratory rate (RR): 20 breaths per minute, oxygen saturation (SpO2): 95 %, blood pressure (BP): 105/57 mmHg, mean arterial pressure (MAP): 73 mmHg and a Glasgow Coma Scale (GCS) was 15 points. The patient manifested dysphagia and had basal hypoventilation on auscultation of the left hemithorax. In the exposure, two bullet holes were found of 0.5 cm in the right zone II of the neck, 1 cm in the left zone III of the neck, and 1.5 cm at the T8 level in the posterior left thorax. None of the injuries presented active bleeding or expansive hematomas. E-FAST and chest radiography showed left hemopneumothorax, so a left drainage thoracostomy was performed.

Angiotomography (CTA) identified a 5 mm pseudoaneurysm in the common carotid artery (CCA) with a small intramural thrombus (Fig. 1a, b, and c). Given this finding, an arteriography was decided. The right femoral artery (RFA) was cannulated with the Seldinger technique, an 8F introducer was placed, and before the administration of 5000 U of intravenous heparin, a guide catheter (Chaperon®, MicroVention, Aliso Viejo, California, EE. UU) was position upon the left CCA. Angiographic findings corroborate the diagnosis of pseudoaneurysm affecting the intima adjacent and superior to the injury (Fig. 1d and e). Proceeding after that with the placement of a 7 mm × 40 mm self-expanding covered stent (Carotid Wallstent®, Boston Scientific, Santa Clara, California, EE. UU) that lines the inside of the vessel and covers the pseudoaneurysm and the damaged intima layer (Fig. 1f). There was no evidence of extravasation upon angiographic follow-up, and the intracerebral circulation was unaffected. Afterward, dual antiplatelet therapy was initiated.

Fig. 1.

Left CCA 5 mm pseudoaneurysm [red arrow], 5 cm from the carotid bulb and 8 cm from its origin in cervical CTA coronal cut (A), sagittal cut (B), and 3D reconstruction (C). Neck arteriography showing a 5.0 mm × 2.8 mm left CCA wide neck pseudo aneurysm, with irregular outline, al C7 level [blue arrow]. Intima affected adjacent and superior to the injury (E) [green arrow]. (F) Left CCA after stent placement [yellow arrow]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Due to prior dysphagia, an esophagogastroduodenoscopy (EGD) was performed, ruling out any hypopharynx or esophagus injuries. The patient remained hospitalized in the Intensive Care Unit (ICU) for eight more days and was then transferred to general hospitalization, where recovery continued. After fourteen days as an inpatient, he was discharged home. At the three-month follow-up consultation, the patient remained asymptomatic, worked, and maintained an active lifestyle without any alterations.

3. Case report 2

A 22-year-old male patient referred from a rural hospital arrives at the ED with a Low-velocity GSW about an hour before admission on the left suprascapular area, without any evidence of active bleeding but a stable hematoma on the ipsilateral cervical region. Additionally, he presented dysphagia and dysphonia. Vital signs on admission were HR: 87 beats per minute, RR: 18 breaths per minute, SpO2: 98 %, BP: 122/69 mmHg, MAP: 83 mmHg, and GCS of 15 points.

CTA revealed compromised continuity of the left CCA at the level of the C5 vertebrae body, with contrast fluid leakage and partial collapse of the left internal jugular vein (IJV) among all its courses (Fig. 2a, b, and c). Then, arteriography confirmed a laceration at the distal third of the CCA with active leakage of contrast fluid (Fig. 2d). A 5 French guided catheter was inserted in the right femoral artery (RFA), and a 7 mm × 40 mm self-expanding covered stent (Advanta®, Getinge, Göteborg, Sweden) was placed, occluding the laceration. Adequate exclusion of the injury was observed on angiographic follow-up, without any leakage of the contrast fluid and with adequate intracranial blood flow (Fig. 2e). After the procedure, dual antiplatelet therapy was initiated.

Fig. 2.

Cervical CTA cervical cut (A), sagittal cut (B), and 3D reconstruction (C). Left CCA wall irregularity and loss of wall continuity at C5 vertebrae [red arrows] was identified, with contrast fluid leakage [yellow asterisk]. Left IJV is partially collapsed in all its trajectory [blue arrow] with contralateral neck structures deviation due to a large hematoma. (D) Distal third left CCA 5.0 mm laceration with active contrast fluid leakage shown in arteriography [green arrow]. (E) Left CCA laceration occluded with endovascular stent placement [yellow arrow]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fibrobronchoscopy (FBC) and EGD ruled out tracheal or esophageal injuries. The patient remained hospitalized in the ICU for five more days and, on the sixth day, was transferred to general hospitalization, where he completed his rehabilitation. After ten days of hospitalization, he was discharged, and in his last medical check-up (one month after the event), he showed no pain and carried out his daily activities without difficulty.

4. Case report 3

A 37-year-old man was admitted from a local hospital to our emergency department because 30 min before admission, he suffered multiple Low-velocity GSW in the cervical and right axillary region. The patient was intubated, and vital signs were the following: HR: 106 beats per minute, RR: 20 breaths per minute, SpO2: 96 %, BP: 100/60 mmHg, MAP: 73 mmHg and a GCS of 6/15. In the exposure, it is evident that wound one at the right axillar area and two 0.5 cm wounds in zone II of the right neck, with active bleeding and expansive hematoma.

The patient was immediately transferred to the operating room, where a right cervicotomy was performed, identifying a 2 cm injury at the distal third of the right CCA involving the bifurcation. Bleeding was controlled with hemostatic forceps and vessel loops, then the damaged arterial segment was resected, and the external carotid artery (ECA) was ligated. Thrombectomy of the right CCA was performed with Fogarty catheter number 3 French. Finally, due to adequate blood reflux of the CCA and the internal carotid artery (ICA), end-to-end anastomosis was performed with a polytetrafluoroethylene (PTFE) graft. A minor injury was identified in the IJV and was repaired with a 6/0 non-absorbable single filament suture (Fig. 3).

Fig. 3.

(A) Distal third right CCA 2 cm laceration, extending to the bifurcation [yellow arrow]. (B) Injured segment resected. (C) end-to-end anastomosis with PTFE synthetic graft between right CCA and internal carotid artery [blue arrow]. IJV suture with 6/0 non-absorbable monofilament [black asterisk]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The patient also required fixation of a right inferior maxillary fracture. In addition, FBC and EGD were carried out, where right vocal cord paralysis and a large hypopharyngeal hematoma were identified. Yet, no tracheal or esophageal injuries were found. A nasojejunal tube was placed on this account, and enteral nutrition (ET) was initiated. The patient was then hospitalized in the ICU, and nineteen days later, he was transferred to general hospitalization. Persistent right vocal paralysis was present in the control FBC, with a severe swallowing disorder, so an open gastrostomy was decided.

Finally, after 31 days of hospitalization, the patient was discharged with home care. At his last medical check-up (2 months after the event), the patient did not present any neurological deterioration, his swallowing disorder improved, and he continued in rehabilitation with phonoaudiology.

5. Case report 4

A 35-year-old male patient is admitted to the ED with multiple Low-velocity GSW at the cervical, thoracic, and right superior limb regions 2 h before his arrival. At admission, his vital signs were: HR: 70 beats per minute, RR: 17 breaths per minute, SpO2: 90 %, BP: 103/70 mmHg, MAP: 81 mmHg, and GCS of 14 points. At auscultation, right basal hypoventilation was found. In the exposure, two tangential wounds were evidenced at the right mastoid region, one at zone II of the right neck with a stable hematoma, one at the right anterior thoracoabdominal region, and two wounds were found in the right arm with mild edema and pain due to mobilization; distal pulses were present with adequate intensity; and capillary refill was <2 s, without any neurological impairment. E-FAST was positive for the right hemothorax, so a closed drainage thoracostomy tube was placed.

A projectile at the right carotid space was detected at CTA, and it was associated with an irregularity of the lateral and posterior wall of the distal third of the CCA without any contrast fluid leakage (Fig. 4a and b). An arteriography of the neck was decided due to these findings, where a 2 mm disruption of the right posterior wall of the CCA was observed near the bifurcation without any contrast fluid leakage (Fig. 4c). In the absence of pseudoaneurysms, active bleeding, or any other disorder, it was considered a minor arterial trauma and was managed conservatively with antiplatelet therapy agents. Additional clinical findings included a right humeral fracture in the distal third that required open reduction and internal fixation. The patient adequately tolerated the procedures and was discharged after seven days in the hospital. One month after the event, he continued in physical rehabilitation of the right upper limb and did not present any neurological deficit.

Fig. 4.

CTA, cervical coronal cut (A), sagittal (B) showing gunshot projectile located at C3 level, in the right carotid space, posterior to the ICA [red arrow]. Discrete irregularity is evidenced at the lateral wall, proximal to carotid bifurcation, posterior to the right CCA [blue arrow] and IJV caliber reduction at the middle portion due to extrinsic compression (yellow asterisk). (C) Neck angiogram showing right CCA posterior wall 2 mm irregularity, in proximity to the bifurcation, without contrast fluid leakage [green arrow], with normal intracranial circulation. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

6. Discussion

Penetrating trauma to the carotid artery is uncommon. However, it is frequently one of the most complex injuries to treat among patients with penetrating neck trauma, being associated with high mortality and morbidity rates [1,4]. It is estimated that carotid artery lesions are present in 6 to 13 % of all neck penetrating traumas, and they represent up to 22 % of every vascular injury in the cervical region [1,5]. The most frequently injured artery is the CCA (73 %), followed by the ICA (22 %) and the ECA (5 %) [1].

The most common mechanism of injury is a GSW, followed by injuries from stab wounds (SW) and, finally, injuries from splinters or shrapnel [[6], [7], [8], [9]]. The incidence of these injuries varies widely between countries and regions. In Europe, Canada, Australia, South Africa, Nigeria, Dubai, Thailand, China, and New Guinea, the predominant mechanism of injury is SW [[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21]]. Contrarily, GSW is the most frequent mechanism of injury in the United States, Mexico, and Colombia [[7], [8], [9],[22], [23], [24]]. Penetrating carotid trauma for blast injury with secondary fragment penetration is frequent in areas of military conflict such as the wars in Afghanistan (2001–2021) and Iraq (2003–2011), the second Lebanon war (2006) or the conflict between the Gaza Strip and Israel (2014) [6,9,[25], [26], [27]].

Additionally, close to 62 % of the patients present associated injuries, and the most affected anatomical structures are the IJV (24,5 %) and the cervical spine (18,5 %) [7]. GSW injuries of the carotid artery have a greater risk of provoking concomitant cerebral, medullar, nervous, and aerodigestive lesions in comparison with SW, especially if the trajectory is transcervical. Contrarily, SW in the neck is more associated with IJV injuries [5,22].

Carotid artery penetrating trauma constitutes a significant clinical challenge to surgeons, and the high morbidity rates are due to three mechanisms. First, there is active bleeding that accompanies these injuries, which increases the risk of an exsanguinating hemorrhage. Secondly, expansive hematomas that compress adjacent soft tissues, including the airways, can cause acute respiratory failure if they are not rapidly secured. Third, cerebral ischemia is associated with embolization or thrombosis of the affected vessel, which can be exacerbated by hypotension, shock, hypoxia, and poor resuscitation [1,5,28]. Mortality in admitted patients with these injuries ranges from 10 to 20 %. However, a significant proportion of patients with these injuries will not survive to reach the emergency department, presenting a general mortality rate close to 66 % [5,29].

Initial assessment and treatment of these injuries should focus primarily on physiological stabilization according to Advanced Trauma Life Support (ATLS) protocols and damage control surgery in the emergency department. Physical examination is considered a safe and trustable strategy to approach vascular injuries if carried out strictly and carefully [2,5] (Table 1). In this manner, if a patient is admitted with clinically severe signs of vascular injury, urgent surgery is indicated. On the contrary, if the patient has severe signs and is stable, responds adequately to resuscitation, or presents mild or suspicious signs of vascular injury, it should be evaluated through complementary studies [2,29].

Table 1.

Vascular injury clinical signs.

Severe signs	Mild signs
•Pulsatile bleeding •Pulsatile or expansive hematoma •Distal pulse absence •Thrill/murmur	•Non-pulsatile bleeding •Non-pulsatile or non-expansive hematoma •Decreased pulse •History of active bleeding or hypotension •Neurological deficit

Taken from Serna, J. J., Ordoñez, C. A., Parra, M. W., Serna, C., Caicedo, Y., Rosero, A., Velásquez, F., Serna, C., Salcedo, A., González-Hadad, A., García, A., Herrera, M. A., Pino, L. F., Franco, M. J., & Rodríguez-Holguín, F. (2021). Damage control in penetrating carotid artery trauma: changing a 100-year paradigm. Colombia médica (Cali, Colombia), 52(2), e4054807. doi:10.25100/cm.v52i2.4807.

Currently, there are a wide variety of imaging studies available to assess hemodynamically stable patients with suspected carotid artery injuries. Throughout the years, doppler sonography has been one of the most common diagnostic Imaging performed due to its low cost, lack of radiation, and the fact that it is a non-invasive test with good diagnostic performance in evaluating zone II neck trauma [1,30]. However, the fact that it is operator-dependent and that vascular injuries in zones I and III of the neck can be omitted, especially in obese patients or in the presence of extensive hematoma or emphysema, puts it at a disadvantage [31]. Computed tomography angiography (CTA) is one diagnostic test widely available in trauma centers. It can accurately detect clinically significant vascular injuries in the neck and provide relevant information on associated soft tissue injuries, the cervical spine, and the aerodigestive tract, guiding whether or not to perform other diagnostic studies and reducing unnecessary surgical explorations. For these reasons, CTA is currently considered the first-line examination for diagnosing penetrating neck injuries [31,32]. Conventional arteriography was for many years considered the gold standard test to diagnose vascular injuries before the advent of CTA. Conventional arteriography has the benefit of being a diagnostic and therapeutic test, and it provides information about the location, severity, and extension of the vascular injury. However, its crucial role is the possibility of therapeutically intervening in hemorrhage control, embolization, stent placement, or temporary balloon occlusion of the involved artery to determine the possible neurological effects of a ligation. Despite this, it is an invasive test that can provoke serious complications, including hematoma, punction site pseudo aneurysm, vascular spasm, thrombosis, atheroma plaque distal embolization, and artery dissection. Furthermore, these complications can lead to permanent central nervous system ischemia with catastrophic neurological sequelae [33]. Lastly, magnetic resonance angiography (MRA) is an option. This test provides an adequate evaluation of posttraumatic carotid dissections. However, evaluation of associated bone injuries is limited, and it is a time-consuming test, which proves unpractical in trauma patients. Furthermore, adequate monitoring of these patients can be complex since some medical equipment or implants are incompatible with the resonator, and the presence of metallic foreign bodies also contraindicates its use. This is why magnetic resonance angiography (MRA) is not a first-line assessment test in these patients [31].

Penetrating trauma to the carotid artery has evolved with time. Ligation used to be the only surgical treatment, yet a wide variety of open and endovascular approaches are currently available [2]. Consequently, in the absence of a neurological deficit, the surgical interventions available are: first, lateral arteriorrhaphy for minor injuries. Second, end-to-end anastomosis in major injuries; always verifying that the anastomosis is not under tension. Third, anastomoses with autogenous or prosthetic grafts for extensive and destructive lesions. Autogenous saphenous vein grafts have been the preferred option for many surgeons for years [1,5]. Nonetheless, prosthetic grafts (polytetrafluoroethylene - PTFE) are also efficient and durable, like autologous grafts [34]. These grafts are beneficial when only one surgeon is available and the patient is hemodynamically unstable or needs other surgical procedures, given that they reduce operating time and restore faster blood flow. Likewise, in patients with polytrauma, for example, in explosive trauma with extremity involvement, where the saphenous vein is not available, prosthetic grafts are of great usefulness [34,35]. On the other hand, temporary shunts have been proposed as a valuable intraoperative complement in patients that require complex CCA or ICA reparation, with the purpose of preserving brain blood flow while a definitive vascular repair is performed, reducing poor neurological results and mortality [36]. Even though temporary shunts are controversial due to a lack of evidence, they can be considered a viable option and a last resort. In fourth place, if the ICA or carotid sinus is affected, the transposition of the ECA can be an excellent option [5]. Finally, if the patient presents poor neurological prognosis criteria (Table 2), absence of distal reflux of the affected vessel, and/or injury of the ECA associated with hemodynamic instability, definitive ligation of the injured vessel is indicated to control the bleeding [2].

Table 2.

Neurological criteria of poor prognosis in penetrating carotid trauma.

•Window time > 6 horas •Coma status •Hemiplegia •Risk of cerebral perfusion edema •Risk of hemorrhagic transformation

Taken from Serna, J. J., Ordoñez, C. A., Parra, M. W., Serna, C., Caicedo, Y., Rosero, A., Velásquez, F., Serna, C., Salcedo, A., González-Hadad, A., García, A., Herrera, M. A., Pino, L. F., Franco, M. J., & Rodríguez-Holguín, F. (2021). Damage control in penetrating carotid artery trauma: changing a 100-year paradigm. Colombia médica (Cali, Colombia), 52(2), e4054807. doi:10.25100/cm.v52i2.4807

Endovascular management has also evolved in the past two decades, especially in posttraumatic pseudo-aneurysm and carotid artery dissection hybrid treatments, offering an alternative to traditional surgical approaches, particularly in patients where surgical repair is challenging [2,37]. Potential candidates for endovascular management are hemodynamically stable or respond transiently to resuscitation patients at admission and whose bleeding control has been achieved in the ED [2,29]. If the patient meets these criteria, a CTA is needed to evaluate the permeability of the Willis polygon and injury extent, which can be partial or complete vessel involvement, a pseudoaneurysm, or an intima dissection. Accordingly, if adequate permeability of the Willis polygon is not demonstrated and there is a significant vascular injury without complete disruption of the vessel or associated with a pseudoaneurysm>5 mm, an endovascular stent is recommended to repair the defect and rapidly restore vascular perfusion, associated with antiplatelet therapy to reduce cerebral thrombosis. In contrast, in an entirely thrombosed vessel or an extensive lesion with a risk of high rebleeding that cannot be approached with an endovascular stent, the contralateral blood flow should be evaluated to consider the possibility of reinforcing the occlusion of the injured vessel with coils [2].

Finally, conservative treatment may be the therapy of choice in selected cases. Its main objective is to avoid unnecessary morbidity. The indications for this management are patients with cerebral ischemia who are not candidates for endovascular therapy, intima defects or pseudoaneurysms smaller than 5 mm, vascular occlusion with a competent Willis polygon, and patients with poor neurological prognosis. Administrating antiplatelet therapy is also recommended to reduce cerebral ischemic risk and subsequent stroke [2].

Lastly, we would like to declare that the purpose of this, besides proportioning a literature review about carotid artery penetrating trauma, is to propose management strategies for trauma teams that not only focus on open surgical exploration but encourage other techniques, such as endovascular repair or conservative management as feasible options to correct and/or control this type of vascular lesions with good results.

Hereunder, a treatment algorithm to assess penetrating carotid artery injuries in two university hospitals and trauma centers is proposed based on a consensus synthesizing the experience acquired during the past 30 years by the Trauma and Emergency Surgery Team in Cali, Colombia (Fig. 5).

Fig. 5.

Carotid artery penetrating trauma management algorithm in two trauma centers at Cali/Colombia. ATLS = Advanced Trauma Life Support; CTA = Computerized Angiotomography.

7. Conclusion

Penetrating carotid artery injuries are infrequent and represent a significant clinical challenge to surgeons due to their high morbidity. High clinical suspicion is needed for diagnoses, and to avoid devastating complications, treatment should be timely. Vascular repair is always preferred over ligation when possible. Even though an open surgical approach is more common, conservative management and endovascular therapies are also viable options, allowing less invasive alternatives to be performed and morbid interventions to be carried out with satisfactory results.

Abbreviations

CCA

common carotid artery

ICA

internal carotid artery

ECA

external carotid artery

RFA

right femoral artery

IJV

internal jugular vein

ED

emergency department

HR

heart rate

RR

respiratory rate

SO2

oxygen saturation

BP

blood pressure

MAP

mean arterial pressure

GCS

Glasgow coma scale

GSW

gunshot wounds

SW

stab wound

CTA

angiotomography

E-FAST

Extended Focused Assessment with Sonography in Trauma

CXR

chest X-ray

EGD

esophagogastroduodenoscopy

FBC

fibrobronchoscopy

PTFE

polytetrafluoroethylene

EN

enteral nutrition

ATLS

Advanced Trauma Life Support

MRA

magnetic resonance angiography

Consent

Written informed consent was obtained from the patient and his family members to publish this case report and accompanying images. A copy of the written consent form is available for review by the editor-in-chief of this journal upon request.

Ethical approval

The present study was exempt from ethical approval in our institution and for the use of images in this publication patients' written informed consent was obtained. This decision was made by the ethics committee of the Hospital Universitario del Valle, Cali, November 30th 2023.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Author contribution

Study conception and design: Carlos Andres Muñoz, Adolfo González Hadad.

Acquisition of data: Carlos Andres Muñoz, José Julián Serna, Alejandro Burgos, Paola González.

Analysis and interpretation of data: Carlos Andres Muñoz, Adolfo González Hadad, José Julián Serna, Paola González.

Drafting of manuscript: Carlos Andres Muñoz, Adolfo González Hadad, José Julián Serna, Alejandro Burgos, Carlos Alberto Ordoñez.

Critical revision: Carlos Andres Muñoz, Adolfo González Hadad, José Julián Serna, Carlos Alberto Ordoñez.

All authors read and approved the final manuscript to submit.

Guarantor

• •Carlos Andres Muñoz - Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle
• •José Julián Serna - Departamento de Cirugía de Trauma y Emergencias, Fundación Valle del Lili

Registration of research studies

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Conflict of interest statement

The authors declared no conflict of interest.