A general understanding of the anatomy is helpful for understanding what occurs with a carotid artery rupture (CAR). The carotid arteries run parallel to the jugular vein on each side of the neck. Their primary role is to supply blood to the head and neck regions. The common carotid artery on the right arises from the brachiocephalic artery, and the left common carotid artery arises directly from the aortic arch. The common carotid arteries then bifurcate into the internal and external carotids on either side of the neck. At the site of the bifurcation is an area in which the arterial walls are naturally thin; this is an area of increased risk. The external carotid artery supplies blood to the neck, face, jaw, scalp, and base of the skull. It also supplies blood to the frontal part of the brain, where thinking, speech, personality, and sensory and motor function reside. The internal carotid supplies blood to the rest of the brain and the cranial nerves, affecting the ophthalmic, anterior, and middle cerebral arteries.
Four primary causes of hemorrhage are associated with CAR (Johnson, 2003): (1) tumor hemorrhage secondary to tumor neovascularity; (2) tumor erosion or vascular laceration of the external carotid branch; (3) formation of a pseudoaneurysm secondary to tumor erosion and/or radiation therapy to the head and neck region; and (4) acute major vessel rupture secondary to formation of a pseudoaneurysm or tumor erosion. The mechanism by which erosion develops is related to the drying process that occurs when the carotid artery is exposed to the environment, either during surgery or secondary to tumor exposure. Surgery also can result in edema formation and decreased lymphatic and/or venous drainage, which may increase the risk of CAR.
EPIDEMIOLOGY AND ETIOLOGY
CAR occurs in 3% to 4% of patients who undergo head and neck surgery, and it accounts for about 10% of deaths from advanced cancer (Warren et al., 2002). Death is caused by exsanguination, with the patient dying within minutes of hypovolemic shock.
RISK Profile
• Cancers
• Head and neck cancer
• Thyroid cancer
• Lymphoma in cervical areas
• Infection, either from the tumor or the surgical site, can lead to poor wound healing, resulting in flap necrosis, fistula formation, and/or hematoma.
• Neck irradiation, either neoadjuvant or high-dose radiation (more than 60 Gy), can be a risk factor.
• Malnourishment, especially low serum levels of protein, iron, and vitamin C, contributes to poor wound healing.
• Middle to older age (i.e., 50 years or older), especially with significant weight loss, poses a risk.
• Co-morbidities can contribute to poor wound healing and wound breakdown. These may include:
• History of diabetes mellitus
• History of general arteriosclerosis
• Renal disease
• Hypothyroidism
• Protein calorie malnutrition
PROGNOSIS
No mortality statistics are available for CAR. However, the prognosis for this patient population is extremely poor. Those who survive a rupture often are left with a neurologic deficit of varying degrees, which occurs as a result of arterial disruption of brain dysfunction.
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
1. Vital signs
• Pulse—rapid and weak
• Respirations—tachypneic, dyspneic
• Blood pressure—systolic blood pressure less than 90 mm Hg, or 20 mg Hg below baseline; or pulse pressure less than 20 torr
• Central venous pressure (CVP)—less than 2 mm Hg
2. Medical history
• Wound infection or dehiscence (or both)
• History of cardiovascular or renal disease
• Hypothyroidism
• Diabetes
• Malnourished state
3. Physical signs and symptoms
• Slow or mild bleeding from the wound, flap site, mouth, or tracheotomy (may be seen 12 to 24 hours before the actual rupture)
• Sternal or high epigastric pain, often several hours before rupture
• Enlargement or increased tenderness of the neck
• Cough with sputum that may or may not be blood tinged
• Pulsation in or on top of the mass
• Reduced temporal pulse on the same side as the tumor
• Visual changes—blurred or double vision
4. Psychosocial signs
• Anxiety
• Fear of bleeding or dying (or both)
• Restlessness
• Irritability
5. Laboratory values
• Hemoglobin—decreased
• Hematocrit—decreased
• White blood cell count—elevated if infection is present
6. Diagnostic tests
• CBC, comprehensive metabolic profile, PT/PTT
• Electrocardiogram
• Pulse oximetry (over 95% is normal for an adult) (Upile et al., 2005)
• Duplex scan to detect narrowing of the carotids
• MRI to help detect nodal fixation to the carotids
• Bilateral imaging of the carotids and vertebral arteries—to help detect bleeding sites and determine the integrity of the circle of Willis in the brain (Johnson, 2003)
NURSING CARE AND TREATMENT
Prerupture care
1. Make sure the call bell is within the patient’s reach.
2. Ensure multiple large-diameter IV access routes at all times for fluid resuscitation and blood infusion.
3. Type and cross-match and screen for multiple units of blood in case rupture occurs.
4. Keep oxygen setup with pulse oximetry available and ready in the room.
5. Keep suction setup available and ready in the room.
6. Provide antibiotic therapy if infection is present.
7. Perform wound care using wet to dry dressing.
8. Obtain nutrition consult to enhance would healing.
9. Discuss code status with the patient and significant others in case a rupture occurs.
10. Ensure ready access to emergency equipment and body substance isolation equipment (i.e., gowns, gloves, goggles) should rupture occur.
11. Assess for signs and symptoms of subtle “herald” bleeding from nose, mouth, tracheostomy site, tumor site, and/or wound (Potter, 2005).
12. Obtain laboratory tests, specifically a CBC, to detect unnoted chronic herald bleeding and poor nutritional status (Upile et al., 2005).
13. Provide humidified air to reduce crusting of the wound and to decrease cough.
14. Monitor intake and output to ensure adequate hydration.
15. Keep the head of the bed elevated at least 30 degrees at all times.
16. Refer the patient to social worker/case manager for emotional support and assistance with finances, power of attorney, and home care or hospice care.
Emergency care
(Box 6-1 lists the contents of a carotid rupture precautions box.)
1. With a gloved hand, apply digital pressure directly to the rupture site.
• If the external carotid has ruptured, position the patient supine with the head turned toward the rupture.
• If the internal carotid has ruptured, nothing can be done to prevent aspiration.
3. Hang normal saline or lactated Ringer’s solution and infuse as quickly as possible to reduce the risk of hypovolemic shock.
4. Obtain blood products on an emergency basis.
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