Challenges in Acute Care Surgery: Zone II Neck Gun Shot Wound at a Remote Rural Hospital

An 18-year-old male was involved in a hunting accident with a 22-magnum rifle, shooting prairie dogs. From investigation at the scene, a bullet apparently ricocheted back from a rock into his right neck with substantial blood loss at the scene. Upon arrival to a local hospital, the patient was alert and oriented x 3 with a heart rate of 120/min, a systolic blood pressure of 120mmHg, an O2 saturation of 98% on room air and a respiration rate of 18. On physical exam he had a large non-expanding hematoma over the right anterior neck with a 2cm puncture wound. His only neurologic symptom was right hand paresthesia. Computed tomography confirmed a large hematoma, no flow in the right carotid artery (Figure 1) and bullet fragments near the vertebral column at the C3–4 level (Figure 2). At approximately 5pm, now 2hr postinjury, the local physicians contacted our team for further guidance and possible transfer to our level 1 trauma center located approximately 400 miles away.

Figure 1:

CT Scan showing lack of flow in right internal and external carotid arteries

Figure 2:

Bullet fragments near vertebral column at C3-C4 level

How Would You Respond?

1. Identify and transfer to the closest local surgeon to perform an operative exploration of the wound with shunting of the carotid artery

2. Transfer the patient, without anticoagulation, to a level 1 trauma center for definitive management

3. Heparin bolus and infusion, and transfer the patient to our level 1 trauma center for definitive management

4. Heparin infusion, and transfer to the closest trauma center.

What We Did and Why:

• C.Recommend heparin bolus and infusion, and transfer the patient to our level 1 trauma center for definitive management

Our decision was based upon the following factors: (1) There was no local surgeon available to take this patient to the operating room which could be argued the ideal next step given his right hand paresthesia, a hard sign of vascular injury, and the CT scan showing no flow in the right carotid artery. (2) The vascular capability of the closest trauma center was unknown. The patient was hemodynamically stable without an expanding hematoma or pulsatile bleeding. (3) While bleeding on anticoagulation is a significant concern, an embolic stroke would be catastrophic.

The patient was transported by a flight team to our institution and intubated en-route. Upon arrival, he was taken directly to the operating room and dosed with an additional 2000 units of heparin in the emergency department to maintain a Hemacron activated clotting time >250 sec. An incision was made along the anterior sternocleidomastoid muscle and the right common carotid was isolated and controlled with a Rummel tourniquet. The incision was extended superiorly where we encountered extensive injury to the carotid bulb involving the internal and external carotid arteries with no antegrade flow into these vessels. We then gained control of brisk bleeding from the internal carotid artery as an occlude clot was released, and we ligated the external carotid artery. Due to the extensive injury to the internal carotid artery (Figure 3), we planned reconstruction with a greater saphenous vein graft. Therefore, we placed an 8Fr Pruitt-Inhara vascular shunt for cerebral perfusion while procuring the graft (Figure 4). We isolated the greater saphenous vein and divided it at the bulb to provide a cuff that would match the common carotid. The vein was placed into a harvest solution while we ligated the ends of the patient’s saphenous vein and placed a sterile dressing over the leg wound. We returned to the neck and verified good flow through the shunt. After irrigating the saphenous vein graft in a retrograde direction to evaluate for patent valves, we occluded the shunt temporarily and placed the graft in reverse direction over the shunt (Figure 5) and sutured the common carotid anastomosis with a running 6–0 Prolene suture. We then removed the shunt from the common carotid, clamped the common carotid just prior to the anastomosis and irrigated the venous segment with heparinized saline, reaffirming no existing valves in the venous segment. The shunt was then removed from the internal carotid artery which was allowed to back bleed prior to placing a Satinsky clamp. We debrided internal carotid to normal intima, transected the vein graft to match the distance and then sutured the saphenous vein to the distal internal carotid artery with 6–0 Prolene. We irrigated the limbs vigorously with heparinized saline, released both the proximal and distal clamps sequentially to flush any residual clot, again vigorously irrigated both limbs with heparinized saline and completed the anastomosis (Figure 6). We first released the distal clamp followed by the proximal clamp and brisk flow was restored to the internal carotid artery through the saphenous vein graft. We irrigated the wounds and closed the subcutaneous tissues with 3–0 Vicryl suture and the skin with a running 4–0 Monocryl suture. The patient tolerated the procedure well with ACTs maintained between 250 and 260 seconds throughout the case. He was transferred to the surgical intensive care unit on a continuous heparin infusion with a PTT goal of 60–80.

Figure 3:

Initial exposure demonstrates extensive injury to the right carotid artery

Figure 4:

Placement of a carotid shunt to maintain cerebral perfusion:

Figure 5:

Saphenous vein graft placed in reverse direction over the carotid shunt

Figure 6:

Completed anastomosis with reverse saphenous vein graft

On hospital day 1, the patient was extubated and physical exam revealed anisocoria with left pupil greater than right, and right ptosis consistent with a Horner’s Syndrome due to a sympathetic nerve injury. He also noted numbness over his right shoulder which the orthopedic spine service felt was due to bullet fragments. He remained in a cervical-collar without additional intervention. On hospital day 2 he was transferred out of the ICU and was discharged home on aspirin on hospital day 5. At 6 weeks post discharge, the patient had equal strength in his upper extremities, with only mild right ptosis and improving sensory loss in the C4 distribution over the right shoulder. At 4 months postinjury, the patient sent a photo of his successful bow hunt, a 6-point bull elk. A year later, his local physician sent a Duplex study of the patient’s right internal carotid indicating normal hemodynamics.