Delayed dx of carotid artery dissection
Would a more timely dx have made a difference?
Facts: An intoxicated adult male in his mid-40’s decides to trim the limbs on a tree in the middle of the night. Despite his inebriation, he wisely fastens a makeshift safety rope around his waist and climbs the tree. Unfortunately, he slips. As he falls about 7 feet, the rope slides up around his neck. He hangs there for at least a minute before friends cut him down. Facts/Chronology: 0121: Arrives in the ED with ligature marks, redness, and swelling on his neck. GCS=8, BP 102/56, P 59. 0138: Vomits and may have aspirated. 0201: BP is in the low 90’s. 0209: First seen by EP. The altered mental state is thought to be due to alcohol intoxication. Low BP raises concern for traumatic hemorrhage.(?) 0233: Orders placed for CT of neck/head and CTA of chest/abd.(?) 0236: Lab orders for CBC, CMP, Drug screen, PT/PTT, and TSH(?). 0243: Pt. has grand mal seizure. Ativan given. Seizure stops. 0315: BP remains in 80’s. 0400: Intubated for CT (now 2 1/2 hours post-arrival). CT head/neck unremarkable. CTA chest/abdomen shows possible aspiration. 0436: Drug screen neg except for BA of 142. 0507: CTA of head/neck ordered. 0523: CTA of head/neck finds a dissection and complete occlusion of the L internal carotid artery. There is also hypo-perfusion of the entire L cerebral hemisphere. IR is consulted and advises heparin only. 0530-1434: Pt. remains in ED and shows signs of herniation while awaiting ICU bed. 1434: Chaplain is called. The patient expires in ED shortly thereafter. The pt's wife consults an attorney. The records are sent to an EM expert for review. Plaintiff Concern: The doctor assumed my husband was just drunk. The ED was totally disorganized. It took way too long to find out what was wrong with my husband. It took forever to get any answers. Defense Arguments: Despite the delay in obtaining a CTA of the head/neck that made the dx of a L carotid artery dissection with complete occlusion, an earlier diagnosis would not have altered the outcome. This was a very severe traumatic hemispheric stroke that was not survivable. While the care was clearly not optimal during the first 4 hours, the neck injury from accidental hanging was the cause of death, not the delay in diagnosis. Result: No lawsuit was filed. Takeaways: * Assuming that an intoxicated trauma patient’s altered mental status is due to alcohol is dangerous. Rule out the worst things first. * ED and DI volumes fluctuate. Staffing every day for surge volumes is impossible * When delays occur, communication with patients and families is critically important. * If your negligence isn't the only cause of death, you're generally off the hook. References: I received the email below from Dr. Bill Smock, a long-time reader of MMI-LFL and a nationally known expert on strangulation injuries. Dr. Smock's own case story and the poster below summarize a standard for strangulation injuries./CP]
Case Story: A 50 yo woman was beaten and strangled unconscious. The victim had multiple visible facial and neck injuries and was taken to the ED by domestic violence detectives and a forensic nurse. When the EP failed to order a CTA of the neck, the detectives and nurse advised the patient to go to a local academic ED for a second opinion. The NP there ordered the neck CTA which showed a Grade 3 dissection of the ICA. She was seen by neurosurgery, admitted, and treated with ASA only. Fortunately, she had no stroke or other adverse events. Comment: The major risk for strangled patients is a vascular injury. I have seen multiple cases of carotid dissections from strangulations and am amazed at how few ED physicians know of the importance of a CTA, even for those without visible external trauma. Readers may contact me if they would like to explore the topic further. Below are the imaging recommendations of the Training Institute on Strangulation Prevention. Bill Smock MD FACEP Police Surgeon, Louisville (KY) Metro Police Department Medical Director, The Training Institute on Strangulation Prevention, San Diego, CA
Click on poster for full size view.
Click on poster for full size view.