Brachiocephalic Vein Injury in a 4-Year-Old Male from Motor Vehicle Accident

Abstract

<h3>Introduction and Objective</h3> We present a case of a 4-year-old male who sustained a blunt injury to the left brachiocephalic vein following a motor vehicle accident. The injury was successfully managed with non-operative therapy consisting of pressure dressing and serial exams. To our knowledge, this is the first report published of blunt trauma resulting in a brachiocephalic vein injury in a child and we present a review of management of these injuries in pediatric patients. <h3>Case Report</h3> A 4-year-old-male presented to our trauma center via ambulance following a head-on-collision in which he was a restrained passenger. The child was hemodynamically stable on arrival, conscious, and complained of left shoulder and right thigh pain. Initial exam and work up was notable for a right femur fracture, left clavicular deformity, left cervical seat belt sign with associated abrasion, and a left chest hematoma above and below the left clavicle. Computed tomography angiography (CTA) of the neck was performed and demonstrated contrast extravasation at the posterolateral aspect of the left brachiocephalic vein at the confluence of the left subclavian and left internal jugular veins. A non-displaced left clavicular fracture was also noted. No other acute traumatic injury was noted to the vasculature of the neck or chest. A pressure dressing was fashioned of layered gauze and placed above and below the clavicle and a cervical collar was then fastened to hold the pressure dressing in place. The patient was admitted to the pediatric intensive care unit and serial exams were performed overnight noting no evidence of hematoma expansion. Hemodynamics and serial hemoglobin checks remained stable during his hospitalization. Orthopedic surgery provided a sling for the left clavicle fracture and inserted an intramedullary nail to the right femur on hospital day two. The child was discharged home on hospital day five. <h3>Discussion</h3> Venous injuries are generally resolved with steady and timely pressure. However, venous injuries located in areas that are anatomically not amenable to direct pressure present a clinical dilemma. The injury in our patient was not only behind the fractured clavicle, but on the posterior aspect of the vein. We elected to apply a pressure dressing on the hematoma both above and below the clavicle, theorizing that it may provide some benefit by compressing the hematoma and providing indirect pressure, essentially recreating the normal anatomy of the retro-clavicular space around the injury. While a rare occurrence, this case highlights the very real occurrence of pediatric central venous injuries associated with rapid deceleration.