{"id":5432,"date":"2011-07-14T20:26:29","date_gmt":"2011-07-15T00:26:29","guid":{"rendered":"http:\/\/crashtext.org\/misc\/aortic-injuries.htm\/"},"modified":"2011-11-01T02:08:19","modified_gmt":"2011-11-01T06:08:19","slug":"aortic-injuries","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/aortic-injuries.htm\/","title":{"rendered":"Aortic Injuries"},"content":{"rendered":"

\t\t \t\t \t\t \t\t\u00a0 \t\t \t\t \t\t \t <\/p>\n

\u00a0<\/p>\n

Aortic Injuries <\/p>\n

<\/span>Traumatic Aortic Disruption (TAD)<\/span><\/h2>\n

<\/a><\/a><\/a>\"\"<\/a><\/p>\n

\u00a0<\/p>\n

Aortic Rupture<\/p>\n

Arch is mobile just distal to L subclavian<\/p>\n

Can also tear major branches<\/p>\n

Secondary to trauma, cpr, t-spine fx<\/p>\n

Suspect if deceleration injury or side impact mva, fall >30 feet, steering column or wheel damage.<\/p>\n

ChestCT-may give false positive c mediastinal hematoma, necessitates aortogram<\/p>\n

TEE-better<\/p>\n

Aortogram-gold standard<\/p>\n

Proximal Descending-most common<\/p>\n

Ascending-80% have associated cardiac injuries<\/p>\n

Manage c esmolol then nitroprusside<\/p>\n

Can get spinal cord ischemia and atrial-aortic fistulas<\/p>\n

ABD CT<\/p>\n

If L hemothorax is seen or periaortic hematoma, strongly consider thoracic dissection\/rupture (J Trauma 52 (4):699 2002)<\/p>\n

\u00a0<\/p>\n

Most recent review supporting helical CT (Emerg Med J<\/i> 2004; 21<\/em>:414-419)<\/p>\n

Best study to date of CTA for aortic injury shock trauma (J Trauma. 1998 Nov;45(5):922-30)<\/p>\n

\u00a0<\/p>\n

Two recent papers expand our knowledge of blunt traumatic aortic injury from resusme<\/p>\n

UK crash data identified risk factors for low impact blunt traumatic aortic rupture, or \u0091LIBTAR\u0092 (crashes at relatively low speed): age >60, lateral impacts and being seated on the side that is struck are predictive of LIBTAR. This study should raise our index of suspicion of aortic injury in low-impact scenarios since low-impact collisions account for two thirds of fatal aortic injuries.<\/p>\n

Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture<\/strong> Emerg Med J. 2010 May;27(5):341-4<\/a><\/p>\n\n

Data from the Victorian State Trauma Registry showed\u00a0pre-hospital mortality from traumatic thoracic aortic transection was approximately 88.0%, whereas patients who survive to reach hospital have a much lower hospital mortality (33.3%, and once patients who arrived in extremis were removed hospital mortality was reduced to 5.9%). Repair was performed in 46 patients, with 22 receiving initial endovascular repair and 24 receiving initial open repair. Mortality rates following surgery were 9.1% and 16.7%, respectively.<\/p>\n

The majority of patients arriving at hospital (57.1%) had an ISS of over 40 highlighting that these patients are unlikely to have only one serious injury and are likely to be more seriously injured than the normal trauma population. An ISS greater than 40 was a main predictor of mortality before repair.<\/p>\n

Aortic transection: demographics, treatment and outcomes in Victoria, Australia<\/strong> Emerg Med J. 2010 May;27(5):368-71<\/a><\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

<\/span>Chest X-ray<\/span><\/h2>\n

Radiographic Clues That Should Prompt Suspicion of a Thoracic Great Vessel Injury<\/b> (Trauma 6th ed) \t\t \t\t\tFractures<\/b> \t\t \t\t\t\u0095\u00a0Sternum \t\t \t\t\t\u0095\u00a0Scapula \t\t \t\t\t\u0095\u00a0Multiple left ribs \t\t \t\t\t\u0095\u00a0Clavicle in multisystem injured patients \t\t \t\t\t\u0095\u00a0(?) First rib \t\t \t \t\t \t\t\tMediastinal Clues<\/b> \t\t \t\t\t\u0095\u00a0Obliteration of aortic knob contour (Fig. 29-3) \t\t \t\t\t\u0095\u00a0Widening of the mediastinum >8 cm (Fig. 29-4) \t\t \t\t\t\u0095\u00a0Depression of the left mainstem bronchus >140\u00b0 from trachea \t\t \t\t\t\u0095\u00a0Loss of perivertebral pleural stripe \t\t \t\t\t\u0095\u00a0Calcium layering at aortic knob \t\t \t\t\t\u0095\u00a0“Funny-looking” mediastinum \t\t \t\t\t\u0095\u00a0Deviation of nasogastric tube in the esophagus (Fig. 29-5) \t\t \t\t\t\u0095\u00a0Lateral displacement of the trachea \t\t \t \t\t \t\t\tLateral Chest X-ray<\/b> \t\t \t\t\t\u0095\u00a0Anterior displacement of the trachea \t\t \t\t\t\u0095\u00a0Loss of the aortic\/pulmonary window \t\t \t \t\t \t\t\tOther Findings<\/b> \t\t \t\t\t\u0095\u00a0Apical pleural hematoma \t\t \t\t\t\u0095\u00a0Massive left hemothorax \t\t \t\t\t\u0095\u00a0Obvious blunt injury to the diaphragm \t\t \t<\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

Best study (274 patients)<\/p>\n

(Fabian T. J Trauma 1997; 42: 374-383)<\/p>\n

Wide mediastinum 221 85% Indistinct aortic knob 63 24% Left pleural effusion 49 19% Apical cap 49 19% Tracheal deviation 32 12% NGT deviation 29 11% Bronchus deviation 12 5% Normal chest X-ray 19 7% <\/p>\n

X-Ray (90-95% sensitive)<\/p>\n

Increased mediastinal width >8 cm at knob<\/p>\n

Indistinct arch<\/p>\n

Opacification of space between aorta and pa<\/p>\n

Deviation of NGT<\/p>\n

Widened paratracheal stripe<\/p>\n

Depression of L mainstem<\/p>\n

L apical pleural cap<\/p>\n

All chest x-ray findings are of mediastinal hematoma which is not the same thing as TAD.\u00a0 10-20% of mediastinal hematomas will turn out to be TADs.\u00a0 Massive hemothorax is the only direct sign of TAD on C-XR.<\/p>\n

\u00a0<\/p>\n

Most recent study casts doubts on utility of supine chest film (J Trauma 2004;56:243)<\/p>\n

\u00a0<\/p>\n

Chest x<\/em> ray did not show obvious mediastinal widening,but incidentally the space between intimal calcification andthe outer border of the aortic arch was >1 cm, a recognisedradiological sign of aortic dissection (fig 1<\/a>). Awareness ofthis is crucial. Troponin was normal but D-dimer was raised.A computed tomography scan confirmed aortic dissection typeB, managed conservatively with intravenous labetolol and analgesia,with a good outcome. ( Gartland et al. 24 (4): 310 — Emergency Medicine Journal)<\/p>\n

<\/span>Helical CT in TAD<\/span><\/h2>\n

Author Total TAD Sensitivity NPV Fabian J Trauma<\/i> 98 494 71 100% 100% Mirvis J Trauma<\/i> 98 1,104 24 100% 100% Dyer J Trauma<\/i> 02 1,338 30 100% 100% <\/p>\n

\u00a0<\/p>\n

<\/span>Signs of TAD on Helical CT<\/span><\/h3>\n

Direct<\/h4>\n

Well visualized flap<\/p>\n

false lumen with flow<\/p>\n

obvious aortic disruption<\/p>\n

Indirect<\/h4>\n

mediastinal hematoma<\/p>\n

abnormal vessel contours<\/p>\n

question of flap on one cut<\/p>\n

\u00a0<\/p>\n

Most Recent J Trauma Study (Volume 56(2)\u00a0 \u00a0February 2004\u00a0 pp 243-250) One center states CT ready for prime time as sole diagnostic test<\/p>\n

\u00a0<\/p>\n

1.\u00a0\u00a0\u00a0 The initial resuscitation should not be aggressive.\u00a0 Keep the BP below 90\/- 2.\u00a0\u00a0\u00a0 NONE should go to CT.\u00a0 Look at the chest x-ray, mechanism and PE,\u00a0 If you are suspicious of an injury from these screening tests.\u00a0 GO TO AORTOGRAM \u00a0 3.\u00a0\u00a0\u00a0 If the mechanism is suggestive, but the Chest X-ray is NOT, then a CT to look for a mediastinal hematoma is indicated.\u00a0 FOR ANY PATIENT WHO YOU ARE GOING THROUGH ALL THESE EVALUATIONS, THEY SHOULD BE ON BETA BLOCKERS UNTIL DX IS RULED OUT OR OPERATION IS COMPLETED \u00a0 4.\u00a0 Only ones to go straigtht to OR are those who are unstable.\u00a0 Stable patients should wait till daylight or up to 3 days acutely if they have extensive associated injury.\u00a0\u00a0\u00a0 \u00a0 5.\u00a0\u00a0\u00a0 CT is a screening NOT DIAGNOSTIC aid.\u00a0 I know of NO case I have seen in the hospital, or those I have seen in consultation in the court room that the CT ALTERED ANYONES DECISION MAKING.\u00a0\u00a0 I AM FAMILIAR WITH FAR TOO MANY CASES THAT THE CT AND TEE were misleading and led to spurious decision making.\u00a0\u00a0 \u00a0 \u00a0 The ATLS does not address the urgency for operation.\u00a0 You will find that in the thoracic surgery and trauma literature.\u00a0 <\/p>\n

<\/span>Delayed Treatment<\/span><\/h2>\n

It may be an acceptable strategy to stage the injury and then perform delayed repair with interim lowering of BP and HR. <\/p>\n

Retrospective Study (J Trauma Jan 2004 56:1) use serial c-xrs to check silhouette <\/p>\n

Shoot for MAP<70 with b-blockers and then nitrites<\/p>\n

\u00a0<\/p>\n

Pacini D, Angeli E, Fattori R, et al. Traumatic rupture \t\tof the thoracic<\/p>\n

aorta: ten years of delayed management. J Thor \t\tCardiovasc Surg 2005;<\/p>\n

129:880-884.<\/p>\n

\u00a0<\/p>\n

\t\t\u00a0 \t\t<\/p>\n

The cardiac surgeons of the Massachusetts General \t\tHospital pioneered<\/p>\n

the immediate medical and delayed surgical management of \t\tpatients with<\/p>\n

traumatic rupture of the thoracic aorta starting in \t\t1971. Since their initial<\/p>\n

report in 1981, several additional series have been \t\tpublished attesting not<\/p>\n

only to the feasibility of such management but to the \t\tactually improved<\/p>\n

outcomes it makes possible. This article from Bologna, \t\tItaly, adds to that<\/p>\n

collection and contributes a new dimension: a series of \t\tpatients treated not<\/p>\n

only with delayed repair but with endovascular stenting \t\trather than via open<\/p>\n

thoracotomy. The charts of 69 patients with traumatic \t\tthoracic aortic rupture<\/p>\n

seen over 23 years were reviewed. Twenty-one, seen \t\tbetween 1980 and 1993,<\/p>\n

were managed with immediate operative repair. Four of \t\tthese died, and 3<\/p>\n

developed paraplegia. Beginning in 1993, patients were \t\ttreated with initial<\/p>\n

medical management, followed by delayed repair. Of these \t\t48, 5 required<\/p>\n

urgent repair, 3 via surgery and 2 via endovascular \t\tstent placement.<\/p>\n

Indications for urgent repair were massive hemothorax \t\tand contrast<\/p>\n

extravasation on CT, rapid enlargement of the \t\tpseudoaneurysm, and<\/p>\n

pseudocoarctation. The remaining 43 had delayed repair, \t\t13 with an<\/p>\n

endovascular stent and 30 via open surgery. Only 2 of \t\tthese patients died,<\/p>\n

and only 1 developed paraplegia. All 15 stent placements \t\twere successful and<\/p>\n

uncomplicated. This is real progress and is certainly \t\tthe direction of<\/p>\n

the future.<\/p>\n

\u00a0<\/p>\n

J Trauma Volume 66(4),\u00a0April 2009,\u00a0pp 967-973-Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.<\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

<\/span>Graft Infection<\/span><\/h2>\n

<\/a><\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

Patients who need to be transferred to other facilities for definitive repair Severe head injury Severe pulmonary injury Haemodynamically unstable patients Patients who have undergone damage control procedures Patients with coagulopathy, hypothermia & acidosis Patients with severe medical co-morbidities Patients with burns or severe sepsis. <\/p>\n

\u00a0<\/p>\n

(2) decrease of the rate of the arterial pulse increase (dP\/dt) to diminish shearing forces.<\/p>\n

\u00a0<\/p>\n

The use of beta-adrenergic blockers (\u03b2-blockers) is the cornerstone of aortic dissection management. Because nitroprusside increases the heart rate and may also increase the dP\/dt, a \u03b2-blocker must be started before or in conjunction with sodium nitroprusside to lower the dP\/dt. Esmolol is an ultrashort-acting \u03b2-blocker that is easily titrated. After mixing 5 g in 500 ml D5W, an initial bolus of 500 \u03bcg\/kg is given, followed by an infusion of 50 to 200 \u03bcg\/kg\/min. Labetalol has both \u03b1-blocking and \u03b2-blocking activity and can be used as monotherapy. A suggested dose is an initial 20 mg IV bolus every 5 to 10 minutes, incrementally increased to 80 mg until a target heart rate has been reached or a total of 300 mg is given. A maintenance dose of labetalol is then given at 1 to 2 mg\/hr. A target heart rate should be between 60 and 80 beats\/min. If a patient is normotensive, a \u03b2-blocker should still be used to lower the dP\/dt. <\/p>\n

\u00a0<\/p>\n

Trimethaphan is mixed as a solution of 500 mg in 500 ml D5W and is infused at a rate of 1 to 2 mg\/min. Trimethaphan is a ganglionic blocker that reduces both arterial pressure and its rate of increase, thus not requiring the use of concomitant \u03b2-blockade. It is more difficult, however, to titrate trimethaphan than to titrate nitroprusside, and tachyphylaxis frequently occurs after 24 to 48 hours.[46] Additionally, the frequency and severity of side effects (e.g., respiratory depression, nausea, urinary retention) limit the use of trimethaphan.<\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

I guess this myth persists still, Karim–in fact ANY patient can get a pretty near-to-uprite film if we want one regardless of their potential injuries or status.\u00a0 You do not have to sit the patient up , that is, bend at the waist , to do this–it is quite easy to put the stretcher in reverse Trendelenberg position, putting the body fairly uprite while keeping the body straight in alignment and shooting the film perpendicular to the body axis–we do this often, there are papers written on it from years back showing its value–we seem to continually forget.<\/p>\n

\u00a0<\/p>\n

\t \t\tJoseph Ayella, the original trauma radiologist at Maryland Shock \t\tTrauma,\u00a0 \t \t \t\tdescribed this technique. \t \t\t\u00a0 \t \t\tThe xray beam must be about ten degrees toward the feet to obtain a\u00a0 \t \t \t\t“pseudoupright” film. If the patient is completely upright, then you \t\tmust\u00a0 increase \t \t\tthe angle of the xray source. However, you must get the patient\u00a0 \t\tsomewhat \t \t \t\tupright so that the xray source can be directed horizontally in stead\u00a0 \t\tof the \t \t\tvertical position for a supine film. \t \t\t\u00a0 \t \t\tThe value of this technique is that it allows the technologist to \t\tincrease\u00a0 \t \t \t\tthe film\/xray source distance to 72 inches which reduces magnification. \t\tThe\u00a0 \t \t\tangle allows a proper projection of the mediastinum. The xray source can \t\tonly go \t \t\t\u00a0vertically about 40 inches. \t \t\t\u00a0 \t \t\tHowever, lest i be seen as a die hard advocate of this technique, I \t\twould\u00a0 \t \t \t\tnot do it in an unconscious patient or in situations of possible spine\u00a0 \t \t \t\tinstability. Not worth the risk and those patients all have to go to CT \t\tanyway,\u00a0 So we \t \t\tcan get a better idea of mediastinal width, hemorrhage etc from the\u00a0 CT <\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 <\/p>\n","protected":false},"excerpt":{"rendered":"

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