{"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":"
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Aortic Injuries <\/p>\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 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<\/span>Chest X-ray<\/span><\/h2>\n