R. Todd Maxson, M.D.Trauma Medical Director

John Recicar, RNNursing Director Trauma CenterArkansas Childrens HospitalEpidural Bleed with a Blunt Carotid Injury

16 year old female previously healthy, high speed rollover

Combative on scene and not moving left side

Intubated on Scene

Rapid transport to Level III TCPre-hospital

Evaluation at OSH

To OR for evacuation of Epidural

Specialized transport team requestedInitial Hospital

Team met patient in PACU

Optimized ventilation

Started a Transfusion

Returned to ACHTransport

Direct admit to PICU

Involved Pediatric Surgery, CCM, Neurosurgery and Vascular Surgery

MRI / MRA done to evaluate brain injury and carotids with non resolved left sided discrepancy in movement

Tertiary Center

Pulmonary contusions

Epidural with a shift

Carotid dissection with pseudoaneurysm

Occipital condyle fractureInjuries

MRA C-Spine**

Quickly extubated and transferred out of ICU

Duplex ultrasound unable to visualize lesion

Aspirin for anti-platelet effect followed by TEG

Lovenox at 60 mg BID for prevention of thrombin conversion with anti Xa level

Tertiary Center

Admitted to Rehab service on day 4 with discharge on day

Continued on Warfarin

Ultrasound study no change in lesion

Follow up with ultrasounds and Vascular SurgeryTertiary Care

Demonstrates all phases of hemostasisInitial fibrin formationFibrin-platelet plug constructionClot lysis

Identifies imbalances in the hemostatic system Risk of bleedingRisk of thrombotic event

Allows for individualization of component replacementWhy use TEG

Remaining QuestionsWhen and How to screen for carotid injuryWhat is the appropriate early treatmentTEG use and level of inhibitionDefinitive treatmentStentLong term anticoagulation - ?**

Should the transport team fully optimize before leaving?Yes to prevent hypotension and hypoxia following TBI Maybe depends on how sick the child is or if a critical intervention is neededNo doesnt make a difference**

What do routine lab test of anticoagulation (PT, APTT) lack that TEG provides?

Ignore altered thrombin generationIgnore cellular elementsIgnore overall clot structure All of the above**