today, Pediatric Complex Case Series, Dog Bite of the Neck. We're really happy today to have Dr. Tony Escobar and his team to present this case study to you. And so I'm going to just give a short introduction for him, and then I'll let him introduce the rest of the team. Dr. Mauricio Tony Escobar, Jr. is a pediatric surgeon and medical director of pediatric surgery and pediatric trauma at Mary Bridge Children's Hospital in Tacoma, Washington, where he recently completed two terms as chief of staff. He has numerous academic and professional honors, including publishing over 40 peer-reviewed articles, 14 clinical textbook chapters, and presentations at multiple national and international surgical meetings, and serves on numerous professional committees in the field, such as the chair of the TCA Pediatric Committee. His academic interests lie in screening for child abuse and bioethics. He led a PTS team in publishing an extensive review of NAP screening in the Journal of Trauma, co-authored the American Pediatric Surgical Association position statement on the role of the pediatric surgeon in screening for child abuse, and recently co-led the task force to develop the child abuse section of the best practice guidelines for the Trauma Center Recognition of Family Violence by the ACS Trauma Quality Improvement Program and the Pediatric Trauma Society. So that's a short bio. Dr. Estimar, thank you for being here with us and the rest of your team. If you want to go ahead and introduce everyone else, then we'll get right into it. Thank you. Thank you, Christine. Thanks, everybody. I am very lucky to moderate a talk by this incredible group of surgeons and anesthesiologists who took care of an extremely complex case earlier this year at the end of last year. My partner, Dr. Randy Holland, who is a senior member of the Pediatric Surgery Group, led a multidisciplinary trauma team in the care of this patient who sustained a significant dog bite to the neck, and Dr. Wes Hart, who was the anesthesiologist that took care of the patient. Dr. Erica King was the Pediatric Otorhinolaryngologist, and Dr. Jonathan Ratcliffe was the Vascular Surgeon. And there were other members of the team that could not be here with us today. Other disciplines included plastic surgery, the Pediatric Emergency Department, as well as the Pediatric Intensive Care Unit. And so I'm very lucky to be able to moderate this incredible group. Okay, the next slide. So our objectives are to describe the management of a complex penetrating injury to the neck, and especially in children, understand the roles of each of the specialists and subspecialists in the management of a complex penetrating injury to the neck, generate a discussion regarding different options for complex penetrating injury to the neck in children, and present the outcome of this complex – excuse me – complex penetrating injury to the neck. Next slide. And we have no disclosures. There you have the team. Okay, so you're in the Emergency Department. You get a call that there's been a 12-year-old male that's been attacked by a pit bull. The attack was reported as unprovoked. EMS has arrived on the scene to find the child lying supine on the floor, bystander holding pressure, over injuries on the neck. The assessment is that the patient is awake and alert. The pulses are strong, regular, and the patient is tachycardic. Noted – EMS notes extensive wounds to the neck and left ear, including a puncture wound near the trachea and a partial ear amputation. Bleeding from the neck is slow but continuous. The patient is placed on oxygen, and two peripheral IVs are inserted. At this point, Mary Bridge is notified. With this, typically I would ask the Emergency Department physicians what they're thinking, what's going into the planning. This is paged out as our highest level of activation, a major. At this point, I'll turn the discussion over to Dr. Holland and Dr. Hart to query what are they thinking when this kind of page comes across. Well, these can be a wide range of severity, and sometimes dog bite is all superficial and there isn't a whole lot to do, but you have to be prepared for an extensive injury, which is what we encountered. So, we gathered the team in the Emergency Department awaiting arrival, and then once we saw the severity and knew that we were going to go to the operating room for, at a minimum, just a wound cleaned out, we decided that controlling the airway immediately would be a benefit. And so, Dr. Hart took over to intubate the patient even prior to going to CT scan because we didn't want an airway issue in radiology. And Wes, before you give your thoughts, can we go on to the next slide? Go ahead, Wes. Wes Hart, when it comes to the management of traumatic airway, it's important to notice the ABCs of the care of the patient. Are they able to manage their own airway? Are they breathing on their own? In which case, this patient was managing his airway and was breathing on his own to some extent. The injuries to his neck were pretty extensive. And so, when you're making considerations of how to manage that airway at that period of time, I think logical advice is to surround yourself with as much talent as possible and the best equipment that you have to manage that. And so, we decided in this case to get the patient off to sleep right there and control the airway right there in the emergency room where Dr. Holland was there in case there was an issue and we needed a surgical airway. A glidescope was used. And on visualization of this kid's airway, this child's airway, he had a very extensive epiglottic tear along with other injuries that made it a rather interesting airway management case, I should say. And so, I think that we were just lucky to have a lot of people with a lot of experience to control this in a pretty safe fashion. I think the other thing to think about in a situation like that is what's the volume status of that patient? This patient was mildly tachycardic but was maintaining a good blood pressure. And we made the estimation at that time that the patient had not lost a significant volume of blood. But that goes with the B and the C of the A that starts first, if you know what I'm saying. Yes, absolutely. And I think this kind of case can be particularly terrifying in a child for any trauma center that's experiencing this. Our first polling question is for the viewers. What type of trauma activation would you have activated? I know they said we did a full activation, but I've certainly been involved. And as Dr. Holland mentioned, you can have a very superficial penetrating neck injury that does not require a full activation. So with the information in hand, what would you do? As we're waiting for people to vote, if the speakers could maybe get closer to the computers, I've got a comment that there's some feedback and it's a little bit hard to understand. I know you're all gathered in the same room, but if you could just do your best to make it a little bit clearer, that would be great. Okay. We'll get close. Okay. I'm going to close this. We've got over 75% and share it. Okay. So I don't know if you can see this, Dr. Escobar, but 79% say yes, full activation, 12% yes, partial activation, and then 9% are unsure. And like I mentioned, that's exactly what we did. We did with the full activation, although we certainly have had partial activations in the past. Can we have the next slide? And this is what Dr. Holland and Dr. Hart and the emergency department team encountered. Next slide. So we went over what the thoughts were when the call was received. Biggest concerns going into the OR was control of the airway. Dr. Hart, whenever you put the laryngoscope or the glidescope down, you said that you saw injury to the epiglottis. When you're thinking about that kind of intubation, especially in a kid, is there anything in particular, any pearls that you could share with the viewers? Because I know with a 12-year-old, that can raise blood pressure and fear whenever we're dealing with something like this. Well, I think, Tony, anytime you have injuries to the neck of this magnitude, your blood pressure can go up a little bit, and you can have concerns. Sometimes it's easy to get lost in the airway when the anatomy is not looking normal. So once again, I think in this situation, having experienced hands trying to safely get an airway with surgical backup immediately available is very important for management. And then, if I recall correctly, this patient was not wearing a seat collar. Is that correct, or do you guys remember? When I got, I think Dr. Holland and myself got to the ER about the same time, and when we got there, there was not a seat collar on this patient. So the management of the airway in a situation like that, trying to keep the neck as stable as possible, but most people would advise to loosen the seat collar until the airway, and then keep the neck as stable as possible in line, and use a glide scope without moving the neck, if possible, to get control. Yeah, and I think most of the audience recognize there is some debate over whether or not penetrating neck injury requires a seat collar, and I think most of the societies have come out in a statement supporting that a seat collar is not necessary. But this one's a little bit tough, because you can think of a dog bite, especially a pit bull bite, as kind of a combination of a penetrating and blunt injury. So let's go ahead and move on to the next slide. So the patient arrives to the trauma bay, awake and alert, able to answer questions, as noted. There were several extensive lacerations, avulsions, and the decision was made, given the severity of the injury, to proceed emergently to the operating room. You can see there that the labs were drawn. Dr. Hart and Dr. Holland made the decision to intubate prior to transport. At that point, the patient is transported to CT and then directly to the OR within approximately 45 minutes of arrival. Next slide. So based on the information you have received so far, how would you manage the fluids on this child? Let's give it another few seconds here. Okay, let me close it and share this. We've got 56% saying fluids based on vital signs, 7% puncture wounds, 12% blood products based on H&H, 20% fluid bolus, and 5% MMB above or unsure. So we'll move on to the next slide. And we'll go through that in just a second. So Randy, do you recall what your approach was to the volume resuscitation in this kid? It was noted that he was stable and it was felt that there wasn't aggressive hemorrhage occurring from the neck. We weren't very aggressive, I don't recall exactly, but we certainly gave some fluid, began fluid in the emergency department to continue upstairs in the operating room. But it was not a massive hemorrhage, nor was he hypotensive. So we weren't aggressive. So I think that there's never anything wrong with falling back on ATLS, a couple of 20 cc's per kilo crystalloid boluses, and then utilize blood as needed depending on how the patient's vital signs are doing. And that sounds like how this case was initially managed and managed throughout the surgery. I think that those looking at this CT scan, Randy, I'd invite you to, what were your findings on this CT scan? And Erica and Jonathan, if you want to jump in to anything that is also noted for you guys. Well, we certainly saw a lot of air in soft tissue, so knew that there was going to be some airway issue or pharyngeal issue. Some air certainly can come in through the lacerations, but there's a lot fairly deep, so it was worrisome. From my perspective, I was also looking at the thyroid cartilage. This is only one slice, obviously, but I didn't see any obvious fracture or anything of the cartilage. And with a kid this age, it's not calcified yet, so sometimes CT can be a little misleading. But overall, I had a pretty low threshold for a pharyngeal skeletal injury. And I think the next slide shows the CTA. Oh, hello, Jonathan here, I'm one of the vascular surgeons, and I was on call this evening. I got a call from Dr. Holland, and I took a look at the CT scan, and as you can imagine, it's quite concerning. My assessment of the vasculature in this case was that, as you can see, there's a pretty significant intimal flap encompassing greater than 25% of the lumen, as well as kind of a rippling and irregularity of the distal portion of the right common carotid artery. So, based on, you know, generally accepted trauma, grading scales with intimal injury as well as the, in some of the cuts, you can see that there's actually a pseudoaneurysm. This was a grade three neck injury based on, you know, blunt type guidelines, but as Dr. Espar previously mentioned, this was a kind of a mixed penetrating and blunt energy mechanism. Location of this injury is in zone two of the neck. And I think that was at the point that I was, so that's what I was dealing with, was a zone two penetrating neck injury with a mixed penetrating and blunt mechanism, you know, but at least grade three injury. Thank you. Can we have the next slide? So, pulling question number three, if this child arrived and you do not have a vascular surgeon such as Dr. Ratcliffe, how do you package the child to stabilize for a pediatric trauma center transfer? Let's give it another second here. Okay. Let's see what we've got. 28% C-collar and backboard, 20% C-collar only, 30% towel neck roll only, 18% towel neck roll and backboard, 5% none of the above. And I think that that is a very telling distribution of answers. Can we have the next slide? As I mentioned before, and Dr. Ratcliffe and Jonathan confirmed, this is a mixed mechanism of injury. So I think that clinical judgment comes into play quite a lot in packaging this patient for transport. Now, moving on, we will move to polling question number four. Okay. Let's see what we've got. Seventeen percent say to the OR and do damage control only. Forty-eight percent to OR to start the process and call in all the specialties. Nineteen percent to OR to explore and then make the decision. Ten percent, none of the choices. Seven percent, unsure. I wonder if the ten percent would have transferred the patients. The next slide. So we discussed a little bit about what the thoughts were from the surgical team. I'd like to actually at this moment ask Erica and Jonathan a little bit more about what they were thinking after having gotten the call and having seen those CT scans. I know you've started that discussion. I just wanted any other thoughts before we move on to how the case is managed. Okay. Tony, this is Jonathan here. So when I first got the call, I took a look at the scan and the first thing I like to do is to take a full assessment of what we're dealing with to have at least some situational awareness. Was the patient stable? Yes. Was the airway secure? Yes. Is there ongoing hemorrhage from soft tissue? It was controlled. Assessment, like I previously stated, well, what injury are we dealing with here? And as we saw, we have a grade three injury, which is a pseudoaneurysm, as well as a large intimal disruption of the distal right common carotid artery in zone two of the neck. Based on pretty established clinical guidelines, any penetrating neck injury in zone two of the neck, if you have a known injury there, it warrants surgical exploration. Next slide. So yeah, I mean, to make matters short, I felt that this just warranted a surgical exploration and repair as indicated based on what we found inside the vessel. What about you, Erin? Oh. Yeah. So, you know, when Randy called me, he was basically, he said, hey, I'm looking at the endotracheal tube through the neck. So, you know, it was pretty clear that there was an injury and that was the first I heard about it, even before seeing the CT. So, you know, again, after reviewing the CT, I already mentioned my thoughts about that. I didn't think it was likely I was going to have to do an ORS of the larynx itself. I was a little bit worried about the vocal cords, you know, was the injury in the trachea? Was it through the cords? Were we going to need to repair any mucosal lacerations? What do you need to do to treat the patient in order to be able to, you know, to repair these things? So, from my standpoint, the first, you know, thing was to try to determine exactly where it was that the injury had occurred. And then, Randy, whenever you first took the patient to the OR, you know, how were you, how did you even approach the exploration? What kind of incision did you do? Did you use one of the lacerations that were already there? How did you come to the conclusion of who you needed to call in? The first person I knew I needed was, after getting the airway by Dr. Hart, was plastic surgery. And they were available, and the two of us are the ones that started. And then we began to look through each of the wounds, assessing each of them. The two largest, most anterior, and just to the left of the midline, we combined, incised through the little isthmus of intact skin to get a better look. And he noted, prior to my seeing it, that there was fluid, clear fluid coming out of that incision. And he was worried about something deep, and he wasn't, in fact, correct. And that's the incision that I looked deeper into, that Dr. Srivatsa, the plastic surgeon, and I explored that specifically. And that's where I saw the endotracheal tube. So that was when we knew we needed Dr. King. As we, prior to that, as we were looking at the wounds, we got reports from radiology saying that there was a vascular injury, and we had helped them calling Dr. Radcliffe to get him to look at things. So I had a lot of help as well, and didn't have to make all the phone calls, and didn't have to delay the surgical intervention to make the assessments and get more people coming. So it was truly a big team effort to manage, explore, and continue to add more team members. Wow. And do you recall how, who helped you coordinate or make those calls? Was it a nurse practitioner, the ED? How did that work? Mostly the people in the operating room, which our nurse practitioner was helping with the operation as well. But our circulator and then Dr. Hart, it helps when your anesthesiologist knows everyone and has everyone's phone numbers. And so that was cheating a little bit, but he helped a lot because he does a lot of vascular anesthesia. So it was a perfect team to facilitate and prevent any delay. We would have gotten there anyway, but it sped up the process. That's fantastic. Can we have the next slide? So I think we've gone over this in detail. Can we go on to the next slide? And here are some of the findings. Next slide. And can you tell us a little bit about the ear, Randy and Erica? What was the, it looks like something's missing. Well, my assessment of this will be quick because I had no idea what to do with this. Plastic surgery was there to help, and their assessment was this is a difficult thing and would require future reconstruction. So he just cleaned and helped partially close things more to make it ready for any future reconstruction. And then Dr. King came later to help with the airway and looked at the ear as well. Erica, did you have any pearls on how you manage something like this? It's clearly, this is not the time for reconstruction. Yeah, so obviously there's an avulsion of tissue. I mean, a lot of times when you've got a laceration, as everyone knows, you can find the flaps of tissue that you think are lost and you actually find them. But in this case, clearly there was an avulsion of really a large part of the helix and part of the antihelix as well. So really the goal here is to make sure you don't have exposed cartilage that's going to end up getting infected and with further loss of cartilage. So I would have done the same thing that the plastic surgeon did and debride that exposed edge a little bit, undermine some of the skin in order to be able to close it over the top, basically. And then you have to come back and deal with it another day with augmentation of the tissue with cartilage, most likely from a rib or somewhere else. Gotcha. Next slide. So Jonathan, would you like to tell us a little bit about what your interoperative findings were in your approach? Sure. Sure. So approach to any vascular trauma, there are a few pretty simple rules, pretty straightforward. Number one, always drape widely and prepare for anything and don't drape yourself out of the operation that you need to do. So Dr. Holland, on the way in, he had already draped the patient widely. We had prepped in the entire neck, upper chest, and then the entire of the lower abdomen and both groins and lower extremities depending on what conduit we needed. Exploration of the neck starts with proper positioning, a shoulder roll, slight extension of the neck, not so much that the head is hanging, turning the head slightly contralateral to your operative site. The incision is made on the anterior border of the sternocleidomastoid muscle. If habitus is a concern, not usually in the pediatric population, but my typical life, bony landmarks can be made and you can essentially draw a line from the sternal notch to the mastoid process and your SCM muscle will be there. So you make a linear incision along the sternocleidomastoid line through the platysma muscle, identify the sternocleidomastoid muscle, mobilize it, retract it laterally. This will expose your internal jugular vein. The vein is fully mobilized. The common facial vein has to be identified, ligated, usually doubly, and divided. By doing this, that opens up the carotid artery and you'll often see the common carotid artery first and that will provide your surgical exposure. This is, again, for a Zone 2 neck injury. This is the standard approach such as for a carotid artery, the same for the trauma. So we did that and you have to make sure to identify the vagus nerve, which is within the carotid sheath, usually posterior and slightly lateral to the common carotid artery, as well as the hypoglossal nerve, which is in the more cephaloid portion of the neck and drapes over the internal carotid artery. So circumferential dissection of common carotid artery, internal carotid artery, and external carotid artery was undertaken very gently because I knew I had an injury there. The main concern in this is, number one, thrombosis and or trauma-involved event leading to a devastating stroke, and then number two, loss of integrity of the vessel. We've got a pseudoaneurysm present in the setting of an area of the gestic tract injury, and so the concern of infection in the neck could weaken the integrity of the vessel. So we explored the vessel and I saw the areas of injury I was making. Number one is if I was going to reconstruct this, I was paying very close attention to the size of the vessel and what would I be using for conduit. Once you open the vessel, it's go time. You have a limited amount of time to make your diagnosis, do your repair, and then place your reconstruction in a child's time is money here. So the injury was to the distal common carotid artery. I had a few thoughts, and I was thinking about this when I was on my way in. What am I going to use for conduit? The following options. Number one, PTFE or Dacron, a synthetic conduit. That's a bad idea in a child, and I would avoid that at all costs except for a bailout situation, hemorrhage, or an unstable patient with a planned return to the operating room to place an autogenous conduit. I just can't really recommend placing plastic in a child's neck, especially with a dirty wound. Options included ipsilateral internal jugular vein, great saphenous vein, or femoral vein. Those are the autogenous conduit options. Based on the location and the size of the common carotid artery, I thought that the patient was pretty small, small patient, that the femoral vein was going to be the best size match. That is a pretty well-established autogenous conduit from the vascular literature for aortic reconstruction in both adult and pediatric patients, and it has excellent patency rates with extremely low rates of infection. It's well-tolerated with minimal complications. I harvested a sufficient amount of femoral vein, placed it in reverse orientation, and then actually placed the vein over a small, straight argyle shunt. The carotid artery was clamped. A longitudinal arteriotomy was performed. I looked in, and sure enough, there was severe disruption of the intima. There was fresh thrombus around the flaps of the intima. Imagine the horror of seeing that. At this point, I had no idea whether there had already been a membolic event that it happened. He did have some good back bleeding from the internal carotid artery, but once I opened this up, the common carotid arteriotomy up to the bifurcation, so right up to where it splits to the internal and external carotid arteries, once I felt that I identified some healthy vessels, I placed a shunt in place, and flow was restored to the human sphere of the brain at this point. The posterior wall of the artery was really beat up from this injury, the blunt component. I think it was the penetrating component that caused the intima disruption, and then just the shaking from this dog is what really disrupted this artery. It was paper thin on the posterior aspect of this. I did not think a simple packing of the flaps and patch was going to be sufficient because the posterior wall of the artery was going to fall apart, and especially if there was any contamination due to the air digestive tract injury, I didn't think it was going to be a good idea. Can we advance the slide? At this point, I had the shunt in place. We confirmed it's the doppler. We had good flow. I was able to just fashion a femoral vein interposition graph of the common carotid up to the bifurcation of the internal and external carotid arteries. Can we go forward one slide, please? One more. Right here. This is what we're looking at after we took the shunt out and finished the femoral vein here. You'll see that in the upper portion of the screen, the suture line there, that's right at the bifurcation of the internal and external carotid arteries. Then you see the femoral vein here appears to be a pretty good size match. You'll see a little bit of it getting larger right up on the distal end, the top of your screen here. That's at a previous valve size, and that little valve was lifed. As you see, the femoral vein's an excellent size match for the common carotid artery. I think that as the patient grows over time, this should continue to be a good repair for him. We're able to get that done. It went pretty well. We're sort of slow. That was kind of my—I finished my portion of the operation. Wow, thank you. And then can we move on to the next slide? Tony, can you go back two slides just to that with the femoral? I just want to touch one other thing. Harvesting of the femoral vein is a great way to go deep in your tool bag to have a good conduit here. An incision is made along the lateral border of the sartorius muscle that's moved medially, and then you'll identify the superficial femoral artery. You dissect that pre, and the femoral vein is right there. Femoral vein harvest is well-tolerated with one caveat. You must preserve and identify the profundiformis vein. It's going straight posterior. That vein cannot be damaged or ligated, or you have to go to a different conduit, because the patient would be at risk for compartment syndrome and phlegmatia if that vein is injured. Thank you, Jonathan. Can we go back to the right there? Perfect. And then, Erica, can you tell us your involvement when you joined and what went forward with you and Randy? Yeah, so I got there pretty much right as Dr. Ratcliffe was wrapping up, and so I scrubbed in, and Randy and I started looking at the neck. As he mentioned, he had joined a couple of the lacerations to create a good-sized incision to look through. The muscles of the straps that were on the left side of the larynx were evolved, it looked like, and it became clear that the location of the injury was the thyroid highway membrane itself was evolved from the thyroid cartilage, and it was through that area that we were able to look in and see the endotracheal tube. Everything inferior to that, the cricoid and the secretor trachea, looked to be intact. So at that point, I went around to the head of the bed and shoved Dr. Hart out of the way, and using his laryngoscope and a zero-degree Hopkins drug, I took a look inside the mouth. I saw that, as he had previously noted, that the epiglottis had been evolved. It was kind of floating around in the hypopharynx to the left of the endotracheal tube. It was still attached with a couple little lateral bands of tissue. So overall, it had been displaced both superiorly and laterally to the left. But we briefly were able to look around the endotracheal tube. At that point, I don't think we actually took the tube out, but it appeared that his vocal folds were intact. And really, the laceration extended about two millimeters superior to the vocal folds, which is where the laceration started. So he was really lucky there. There were no mucosal lacerations in the endolarynx. It was just really the epiglottis that was evolved off. Next slide. So the first thing we did was try to get the epiglottis back into the right position, anterior to the endotracheal tube. So if I recall, Randy grabbed the tip of it with an Alice clamp through the neck while I used a little bit of pressure from inside. And then we brought it into the correct position. I was a little bit concerned at one point that we had rotated it 360 degrees. But it really was just attached by a couple of very tenuous bands laterally. After we got it into a good position, it looked like it wasn't rotated. I closed the pharyngeal mucosa with 6-OPDS sutures. Then I attached the epidural, the little tip there of the epiglottis to soft tissues in the larynx, just superior to the anterior commissure with the 5-OPDS. And then I repaired the thyroid membrane over the top of it with 4-O-Micro. We then repaired and sutured the strap muscles, closed over the midline, and then closed the skin. And at that point, we were pretty much done. And the patient remained intubated and was transported to the PICU. Next slide. So the patient remained intubated for a couple of days, waiting for airways flowing to come down. And kind of the next decision point was, you know, can we get this tube out safely? I think we're all a little bit worried about extubating at the bedside and just taking our chances. So on post-Op Day 5, we decided to go back to the OR to put the scope in there again and assess right anus for extubation. I was strongly hoping to see if the epiglottis wasn't necrotic, which fortunately it was not. As you can see there in the top left picture, you know, the epiglottis is that sort of hunk of meat on top of the endothracial tube. You can certainly see some granulation tissue there, but it was intact and in pink and looks good. So at that point, it felt safe enough to withdraw the endothracial tube. The lower pictures there are after that. The vocal cords, again, were intact and advancing into the upper airway. Again, there was no injury at all to the trachea. So at that point, it felt that he was safe to be extubated. And later that day, he went back to the PICU to emerge from intubation and for extubation a couple hours later. Next slide. Tony, do you want to talk about the PICU story? Yeah. Randy, you're welcome to. How did things progress following surgery? Well, I believe the most amazing step in all of that is within about five minutes of awakening and being extubated, he began to complain that our video games were substandard. That was one of the most heartening complaints I'd ever heard. It made us all feel very good. Excellent. He had no other thoracovabdominal injuries, so we weren't too worried about intestinal problems or anything. He had been started on feeds previously, and then we watched afterwards, and he was able to handle his saliva well. Erica, do you remember anything about swallowing? No, I mean, I was clearly very worried he was going to be aspirating quite a bit. The swallow study looked better than I thought, and he did well with Nectar 6. So, you know, we had him there for a couple days, advancing on the feed, making sure he was going to tolerate enough PO that he didn't have to go home with an NG tube. He actually did pretty well. Obviously, I was a little bit worried about his voice, but since he didn't have a vocal fold injury, you know, I was not too concerned about it. He was a little hoarse and raspy, but for the most part, he actually had a good voice as well. And then you chose to continue antibiotics for 10 days following the attack? I think it was a combination of, you know, many soft tissue injuries. A simple dog bite probably would not require that much antibiotic therapy, but having a vascular graft and an airway compromise, marginal soft tissue, probably worth the overtreatment, if you will. Right. And then you and Plastics and others and Jonathan and Erica saw him following his discharge. We have the next slide. Oh, so this question is for the audience. And then. We'll see what they would have done. We have 2% ED, 12% ICU, 56% Floor, 28% First Outpatient Follow-Up Care Clinic, and 12% Unsure. And just for clarification, you know, there is a certain time frame where we can use the term PTSD following the injury, before that I think it's acute trauma syndrome. Go on to the next slide. And then Randy, do you want to talk a little bit about, and Erica, the follow-up after he was discharged? Well, regarding the PTSD, we have an outstanding neuropsych department, and they were involved early on and continue to do outpatient as well. I believe he was assessed while still in the ICU because he had a fairly prolonged ICU stay even after he was awake just watching his airway, and so they were involved fairly early and continued post-hospitalization follow-up as well. He had close follow-up from all of us after discharge, just to make sure things were okay, and he certainly had some stress and PTSD, but seemed to recover fairly quickly. From my standpoint, he healed up well, and then he was left with issues that Dr. King and Dr. Radcliffe would have to follow longer in the plastic surgery as well. So I didn't follow his ear myself, but unfortunately the plastic surgeon who treated him isn't with us any longer. So just from reviewing the chart, this is a picture from about a week post-op. I think this is at his first post-operative check-in clinic where they moved the sutures. Again, it was healing well without any evidence of infection, but obviously pretty visible deformity. Next slide. His neck incisions actually looked pretty good, considering a little bit of, I guess, some central necrosis there in the middle, but ultimately, again, not a lot of sign of infection or induration. Next slide. From a vascular standpoint, post-op evaluation and management of this is number one clinical. We saw the patient along with our pediatric trauma team, and the patient had no focal neurologic deficits. He had normal motor function of his tongue. As I said, the hypoglossal and vagus nerves are in play. He had no major voice changes other than what would be expected for his airway and epiglottic injury. His wound healed well. We had a follow-up duplex ultrasound in the early post-operative period confirming patency without hemodynamically significant stenosis. Then we also did a follow-up CT scan, CT angiogram of the neck, and had about one month post-op, and we did all the normal reconstructions, and everything looked great. On the right side of your screen, this is actually a photo of when he first came in. I've seen a pseudoaneurysm, and you'll see the regularity of the vessel there when we first came in. This is the best representation of where the injury actually was. He had a follow-up CT scan at one month, and everything looked excellent with a widely patent vessel and good seismic. Next slide. I think by the time I saw him a few weeks after discharge, his voice was actually at baseline. He was still sickening, but very soon after that visit, he was able to wean off of them without any further aspiration. Again, I didn't talk to him too much about anxiety and whatnot, but apparently at this point, six months afterwards, he was able to be around dogs without having too many issues with it. I think you've already talked about your plan to get another CT in a few years. Yes. Clinically, doing well. The CT looks so good. I'm not so worried about stenosis as much as I am about falling for aneurysmal degeneration. It can happen within these grafts. He's thin enough that if it became a really big problem, you could actually steal it. He's actually been in contact with our EMR periodically with his pediatrician. If there are any clinical changes or pulsatile nick mass, that will be properly evaluated earlier than scheduled. He has a planned CT scan, I guess, about two years from now, a year and a half from now. Go to the next slide. Our plastic surgery colleague saw him just last month. This is what his ear is looking like now. Again, it's healed relatively well. Next slide, please. He does have a pretty significant cosmetic deformity. It sounds like right now, he and his father are not totally agreed on whether or not he's going to move forward with reconstruction in twins. It's a little bit up in the air, but I think they have a tentative plan to do a costal cartilage graft sometime within the next year. You can see his neck incision, it's actually healed up rather well. Thank you. Go to the next slide. I want to thank the panelists very much. This is an incredible case. It's an incredible save. What an incredible collaboration. Thank you so much for taking the time to present. Then we will open up to questions. If you'll just type your questions in the question box or raise your hand, we have about 10 minutes. I do have one question. It may have already been answered. Was the sassinus preserved? Is that how you say it? Sassinus? Sassinus, yeah. Sassinus vein wasn't option deficient. The question was, would the sassinus vein have been an easier or better conduit? Is that the question? It says, it asks if it was preserved. The sassinus vein was preserved, yes. Great sassinus vein was preserved in this case. We took a quick look at it and I didn't think it was not going to be a good size match. Until I left it alone, no ties were put on it and it wasn't surgically disturbed. It is in play in the future if future reconstructions need to be done. Was this the child's own pet? No. This was his mother's boyfriend's dog. Okay. I don't have any other questions yet. If you raise your hand instead of typing, I can unmute you if you called in. Here's another question. Why was the child saved by methadone and is that routine? I guess I would say our critical care doctors are generous with narcotics and sometimes it takes a little while to get them back off. Especially with someone who's been intubated purposefully for airway protection for several days. That tends to be something that we see. I am not seeing the question, so I'll let you read them out. I don't have any other questions. I'll just say thank you for answering them. If you come up with any questions, if the attendees, listeners have any questions afterwards, I can always forward them on if you don't have time right now. I don't see anyone else yet. Great presentation, everyone. Getting good feedback. Okay. Let's give it another minute. We have about seven minutes. Okay, I don't have any other questions. They said they like the polling questions. I think those were great to have the interactive polling questions. So, if you all don't have anything else, just thank you so much for taking the time to do this. Well, thank you. Thank you. I really appreciate you guys. Thank you. Thank you. Have a great day. Bye, everyone. And I'll send out the evaluation to everyone. Look for that and send me an email if you have any questions. And we'll forward those on. Thank you so much. Have a great day, everyone. Thank you. Thank you. Bye-bye. Bye-bye.

pediatric surgeon

dog bite

neck wounds

carotid artery injury

surgical exploration

epiglottis injury

ICU

follow-up care

positive prognosis