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Trauma ligation arterial hemorrhage


Grand Canyon Coders
Best answers
Could anyone help with the CPT code for this procedure? I appreciate your help!

PREOPERATIVE DIAGNOSIS: Status post assault with hemorrhaging
laceration, left temporoparietal scalp wound.
POSTOPERATIVE DIAGNOSIS: Same with arterial hemorrhage.

PROCEDURE: Exploration of wound, ligation of bleeding vessels for
FINDINGS: 2-mm arterial branch transected within the laceration that
was bleeding and a large vein, approximately 3 mm that was also
bleeding as well. Patient was hemostatic at the end of the case.

PROCEDURE IN DETAIL: This is a male who was assaulted
this morning with an unknown object and came in with a very large scalp
laceration that was hemorrhaging in the field and continued to
hemorrhage despite pressure dressing and packing with hemostatic
dressings. It slowed the bleeding but did not stop it. Therefore, I
elected to take the patient to the operating room prior to the CAT scan
secondary to the degree of hemorrhage and the amount of blood lost in
the field and in the trauma room. Patient is intoxicated but gave
verbal consent but as an emergency, the patient was taken without
official consent.
After appropriate prep and drape in the usual sterile fashion, the
wound was explored, a self-retaining retractor was utilized and a 2-mm
transected artery was noted and both ends were actively bleeding. They
were both ligated with 2-0 Vicryl suture and became hemostatic. There
was also a 3-mm vein that was noted to be transected that likewise was
ligated and then hemostatic. Copious irrigation of the wound then
followed. Small bleeders, both from the temporalis muscle as well as
from the skin and subcutaneous tissues were cauterized. Another small
bleeder was noted and was oversewn with Vicryl figure-of-eight suture.
I irrigated again copiously. No further bleeding was noted. 1/4-inch
Penrose drain was left in place and sutured to the edge of the skin
wound and the wound was closed with staples. The wound was dressed
appropriately with 4x4s and then Kerlix. Needle, sponge and instrument
counts were stated to be correct at the end of the case. Patient
tolerated the procedure well. There were no complications and patent
was extubated and taken to the recovery room in stable condition.