C is for carotid injury.

A 27-year old Italian woman presented as a trauma call to our accident and emergency department. She spoke no English. There was a vague history from the ambulance crew of a glass being thrown against a wall and small glass fragments ricocheting onto her neck. Witnesses reported an initial spurting of blood from her neck, to which direct pressure was applied. Alcohol and cannabis had been consumed. Primary survey revealed a patent airway and a respiratory rate of 18 breaths/minute. Observations showed 100% oxygen saturation on 15 L of oxygen, blood pressure of 106/52 mm Hg, heart rate of 110 beats/minute, and Glasgow Coma Scale score of 15/15. There was no external sign of hemorrhage. Neck inspection revealed a 3-mm crescent-shaped laceration over her left sternocleidomastoid muscle. There was no ooze, bleeding, or expanding hematoma. Secondary survey detected no other injuries. Arterial blood gas analysis showed a hemoglobin level of 12.3 g/dL, venous lactate level of 3.6, and base excess 1.0. A period of observation with intravenous fluid resuscitation and analgesia was commenced. A plain neck radiograph and an interpreter were requested. The patient continued to complain of disproportionate pain at the site of the neck laceration. A repeated blood gas analysis showed a venous lactate level of 3.3 and base excess of 5.2 despite crystalloid resuscitation. There was still no visible sign of hemorrhage. Urgent computed tomography angiography was performed. This showed a small, triangular shard of glass embedded in the left common carotid artery with a surrounding hematoma (A). The patient was taken urgently to the operating room for a neck exploration. Operative findings were consistent with the computed tomography angiogram. The glass fragment was visualized early. Proximal control of the left common carotid artery was achieved. The glass fragment was removed, revealing a linear 8-mm laceration of the left common carotid artery (B). This was repaired with minimal obstruction to blood flow (C). The patient made an uneventful recovery and was discharged home on the third postoperative day. This case highlights the ability of high-velocity glass fragments to penetrate the skin and to cause significant morbidity in the absence of obvious external signs of injury.