Journal reading: Traumatic Rupture of Aorta

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Journal readingTraumatic Rupture of Aorta

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Traumatic Rupture of Aorta Should Be Ruled Out in
Severe Injuries from Paragliding Report of Three
Cases

• Navarrete-Navarro, Pedro MD Macias, Ines MD
  Lopez-Mutuberria, Maria Teresa Perez, Jose
  Miguel MD Manzano, Francisco MD Garcia, Manuel
  MD Rodriguez, Aurelio MD
• From the Critical Care and Emergency Department,
  Virgen de las Nieves University Hospital
  (P.N.-N., I.M., M.T.L.-M., J.M.P., F.M., M.G.),
  Granada, Spain, and Division of Trauma Surgery,
  Allegheny General Hospital (A.R.), Pittsburgh,
  Pennsylvania
• J Trauma, Volume 52(3). March 2002.567-570

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Background

• Granada, Spain
• Paragliding

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Introduction

• Most frequent injuries related to paragliding
• Bone fx lower limbs, pulvis and spine
• Ruptures of the descending aorta (TRA)
• Very high mortality
• Higher incidence of surviving pt dx with TRA in
  ER then before
• Survival depends on early Dx and Tx.

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Case 1

• 35 y/o male, crash-landed
• Transported by helicopter and received 2L of
  crystalloid fluids, analgesia, and oxygen.
• Awake and lucid. RR 25, BP 90/45, HR 115
• X-ray
• Bilateral legs T-F fx (Rt tibial open fx)
• Both ankle comminuted fx
• L1 L4 vertebral bodies fx.

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Case 1 Chest X-ray

• CXR
• Mediastinal widening and loss of contour
• Descending aorta

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Case 1 Helical chest CT with 3D reconstruction.

• Pseudoaneurysm
• 2cm distal to the origin of the left subclavian
  artery.

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Case 1 Management

• Lower limb fx external fixation
• ICU 24 hr Labetalol ivf to keep SBP lt 120 mm Hg
• Surgery for repair of the aortic rupture
• CP bypass 56 min, Vacutex-type tube implanted
• Post-OP stable
• 48 hr later, progressive left hemothorax
• Repeat CT large periaortic hematoma
• Immediate exploratory thoracotomy drainage
• No evidence of prosthetic dysfunction.

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Case 2

• 39 y/o male, crashed into a tree.
• Good consciousness, abundant facial bleeding,
  bilateral otorrhagia, and upper airway
  obstruction.
• Transported by helicopter
• Sedation, tracheal intubation with MV.
• 2.5 L of cry. coll. fluids.
• Could be aroused.
• FiO2 0.5, PaO2 80 mmHg, PaCO2 31.6 mmHg
• BP 100/60, HR 110

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Case 2 CXR and CT

• CXR
• mediastinal widening with loss of aortic arch and
  contour
• Chest CT
• mediastinal hematoma
• minimal left pleural effusion
• anterior subcutaneous emphysema
• Fracture of the left 6th rib
• Aortogram
• Rupture of the descending aorta 2 cm distal to
  the origin of subclavian artery with formation of
  pseudoaneurym of 4-5 cm.

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Case 2 Management

• OP CP bypass (29 min), Dacron 7 graft implanted.
• Post-OP hemodynamically stable
• Respiratory failure
• FiO2 0.8, PEEP 15 cm H2O
• 4 weeks later, s/p tracheostomy and
  osteosynthesis for facial bone fx
• Discharged with tracheostomy cannula

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Alhambra Granada, Spain
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Case 3

• 29 y/o male, crash-landed
• At the scene
• Both ankle fx with pelvis deformity
• Transported by helicopter
• 3 L of crystolloid fluids
• Analgesia and O2
• Awake and lucid. RR 28, BP 80/40, HR 118
• No evident chest deformity or external injury

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Case 3 CXR and CT

• X-ray
• Bilateral comminuted fracture of the tibia at the
  ankle
• Open-book complex fracture of pelvis
• CXR
• Mediastinal widening and loss of contour of
  aorta.
• CT
• Pelvis major retroperitoneal hematoma
• Chest mediastinal widening with minimal left
  pleural effusion.

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Case 3 angiography

• Rupture of the descending aorta
• 2 cm distal to the origin of subclavian artery
• with formation of pseudoaneurym of 4-5 cm

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Case 3 Management

• Reduction and ext. fixation of pelvis and ankle
  fx.
• Labetalol ivf to keep SBP lt 120 mmHg.
• At 72h after admission
• CP bybass (29 min)
• Resection of injured aorta, Dacron 7 graft
  inplanted.
• Post-OP
• Acute lung injury, with MV for 12 days.
• Extubated after 16 days.
• After 23 days, he was discharged to ortho. dep.

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Discussion

• Protective measures of paragliding
• Crash helmet
• Dorsal spinal protection
• Improved footwear
• TRA
• 2nd most cause of death in (First place H.I.)
• Traffic accidents
• Falls from a height
• 85 die before arrival
• 50 mortality among who arriving alive

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Discussion (2)

• TRA is more common in ER, due to
• Improvements in out-of-hospital stabilization
• Speed of transport
• TRA cases alive in ER
• self-selected group
• 80 the injury is produced at the aortic isthmus
• tear is usually limited and contained

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Discussion (3)

• Diagnostic tools
• Angiography golden standard
• Chest spiral CT
• For dx of TRA. (J Trauma. 1998 45 922-930 )
• Routine use as first line regardless of the CXR
  (Arch Surg. 1998 133 1084-1088 )
• TEE angiography, but less sensitive, being a
  poor first-line exam tool.

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Discussion (4)

• Pre-OP management
• instituting a hypotensive regimen
• Beta-blockers, vasodilators, sedatives, and
  analgesics
• Control BP before OP and 24-48 h after.
• prioritizing the injuries
• intraabdominal hemorrhage
• Craniotomy for cerebral decompression

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Discussion (5)

• Operation options
• clamp sew technique
• operative neurologic sequelae due to spinal cord
  ischemia
• doesnt need heparin (suits exsanguinating
  hemorrhage episode)
• Full cardiopulmonary bypass
• bleeding from other sites of injury due to
  heparin
• Passive shunts (Gott shunts, LV/ascending aorta
  to descending aorta )
• Left heart bypass with a centrifugal or roller
  pump

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Routine CT scanning for primary evaluation of
blunt chest trauma
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Do We Really Need Routine Computed Tomographic
Scanning in the Primary Evaluation of Blunt Chest
Trauma in Patients with "Normal" Chest Radiograph?

• Exadaktylos, Aristomenis K. MD Sclabas, Guido
  MD Schmid, Stephan W. MD Schaller, Benoir MD
  Zimmermann, Heinz MD
• From the Trauma and Emergency Unit (A.K.E., G.S.,
  B.S., H.Z.) and the Department of Visceral and
  Transplantation Surgery (S.W.S.), Inselspital,
  University of Berne, Berne, Switzerland.
• J Trauma, Volume 51(6), December 2001. 1173-1176
• Blunt chest trauma
• 63 - 78 caused by motor vehicle crashes (MVCs)
• 10 - 17 related to fall from height.
• Study focus
• How many chest injuries remain undetected if
  chest CT is obtained only after pathologic chest
  radiograph finding.

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Materials and methods

• University Hospital of Berne (Level I accident
  and emergency unit)
• Inclusion
• January 1999 to July 2000, 93 patients
• MVC (10-95 mph)
• Fall from height (5-35 ft)
• Exclusion
• Hemodynamic instability
• Necessity for rapid surgical intervention
• MF 7815, mean age 48 y/o (17-87)

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Materials and methods (2)

• ER to CT room
• median transportation time 5 min
• Outside of ER 45 to 60 min
• Accompanied by ER physician and anesthesia team
  with full monitoring.
• No complication
• Helical contrast-enhanced CT were obtained in 0.3
  2 hours after arrival in the ER.

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Results

• MCV fall from height 76.3 23.7
• Isolated chest inj multiple inj 2.2 97.8
• 73.1 has at least 1 pathologic sign on CXR
• 25 patients (26.9), the initially obtained chest
  radiograph was normal
• However, in 13 (52.0) of these 25 patients, the
  CT scan showed multiple injuries
• 12 patients (13 of total) both image were normal

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Results (2)
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Plain chest radiographs compared with helical CT
scanning
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Patients with pathologic signs on the chest
radiograph
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CT Scan Findings in 13 of 25 Patients with Normal
Chest Radiographs
CXR (compared with CT) PPV (positive predictive
value) 0.86, NPV 0.48 Sensitivity
(true-positive rate) 0.81. Specificity
(true-negative rate) 0.57
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Discussion

• In Europe, in blunt abdominal trauma, US has
  practically replaced DPL for the search of
  hemoperitoneum
• Reliable, if operator has short period of
  experience.
• Primary routine helical CT scan in blunt chest
  trauma under debate
• Even experienced radiologist may mis-read.
• Occult pneumothorax (esp anterior) only
  detectable by CT in 40 of traumatic cases.
• 1990 Woodring, and Woodring and Dillon 7 of
  thoracic aortic injuries have a normal chest
  radiograph.
• Demetriades et al. helical CT scan has a
  sensitivity of 100 in detecting aortic injuries.

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Discussion (2)

• Angiography
• Brasel et al., in a cost-utility study, suggested
  the routine use of thoracic angiography as a
  screening method in all patients with a
  significant chest trauma, regardless of the
  findings of the plain chest radiograph.
• Demetriades et al. recommend aortography over
  chest CT scan only in patients who need
  angiography for pelvic or hepatic studies anyway.
  
• clinical outcome also controversial

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Discussion (3)

• Risk of a thoracic injury in an MVC is 14
• Sternal fractures 8 of patients of above
  population.
• Risk of cardial contusion and other related
  injuries ??
• Risk of aortic rupture not increased
• Viano et al. and Katyal et al.
• intrathoracic damage occurs before the maximum
  compression of the chest wall is reached
• oscillating viscous response of the aorta.
• Demetriades et al. recommend
• that all trauma patients with high-risk
  deceleration injuries
• should undergo primary routine helical CT scan
  evaluation of the mediastinum irrespective of
  chest radiographic findings.

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Conclusion

• Significant thoracic/intrathoracic injuries found
  on CT scan in more than 50 of patients with
  normal initial chest radiograph.
• Recommend primary routine chest CT scan in all
  patients with history of MVC
• gt 10 mph in unrestrained passengers.
• gt 30 mph in restrained passengers.
• Recommend a CT scan even if the height fallen lt
  15 ft.
• Low falls are as dangerous as falls from higher
  heights
• The height fallen does not predict the risk for
  serious injury.

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Further reading ATLS
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ATLS Thoracic trauma - Primary survey

• Airway fx which compromises airway
• Breath
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive hemothorax
• Circulation
• Massive hemothorax (gt 1500 ml)
• Cardiac tamponade

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ATLS Thoracic trauma - Secondary survey

• Simple pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobronchial tree injuries
• Blunt cardiac injury
• Traumatic aortic disruption
• Traumatic diaphragmatic injury
• Mediastinal traversing wounds

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ATLS Thoracic trauma - Traumatic aortic
disruption

• Common cause of sudden death after automobile
  collision or fall from great height.
• Pt who survived
• Incomplete laceration near the ligamentum
  arteriosum of the aorta
• Intact adventitial layer
• Contained mediastinal hematoma
• Chest x-ray, especially the supine view, are
  unreliable
• Angiography is the golden standard.

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Radiologic signs suggest major vascular injury of
chest

• Widened mediastinum
• Obliteration of the aortic knob
• Deviation of the trachea to the right
• Obliteration of the space between th pulmonary
  artery and the aorta (AP window)
• Depression of the left main stem bronchus
• Deviation of the esophagus (NG tube ) to the
  right
• Widened paratracheal stripe
• Widened paraspinal interfaces
• Presence of a pleural or apical cap
• Left hemothorax
• Fx of the 1st or 2nd rib or scapula

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Radiographic features of Traumatic aortic injury

• Hememediastinum
• Widened mediastinum
• gt 8 cm at aortic arch (supine)
• Med.-Chest-width radio gt 14
• Blurring of the aortic contour with indistinct
  margins
• Left apical pleural cap
• Widening of the left paraspinal stripe
• Opacification of the aorticopulmonary window
• Widening of right paratracheal stripe
• Left pleural effusion
• Displacement of adjacent stuctures
• Tracha rightward and anteriorly
• Left mainstem bronchus inferiorly (bronchus and
  spine angle gt 140)
• Esophagus (NG tube) rightward and posteriorly
• Injury to adjacent thoracic structures

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Thanks for your attention and comments!