Traumatic aortic transection

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Not to be confused with nontraumatic thoracic aortic dissection

Background

  • Blunt traumatic mechanism, rapid deceleration
  • Often asymptomatic but die without warning (80% die at scene)
  • Hypotension NOT from ruptured aorta (just die)
  • Need high suspicion to diagnose

Classification

  • Classification based on CT findings[1]
    • Type I: Intimal tear
    • Type II: Intramural hematoma
    • Type III: Pseudoaneurysm
    • Type IV: Rupture (free rupture, periaortic hematoma)

Clinical Features

No signs or symptoms are sufficiently sensitive for dignosis[2]

Symptoms

Physical exam

  • Seatbelt or steering wheel sign
  • New murmur
  • Subclavian hematoma
  • Femoral pulse discrepancy
  • Upper extremity hypertension

Differential Diagnosis

Thoracic Trauma

Evaluation

  • CXR
    • Widened mediastinum (>8cm on supine film)
    • Left apical cap
    • Enlarged aortic knob
    • Left hemothorax
    • Rightward tracheal/esophageal deviation
    • Depression of L mainstem bronchus
    • Elevation of R mainstem bronchus
    • Widened paratracheal stripe
    • Widened paraspinal interfaces
  • CT
    • Diagnostic study of choice
    • Good for aorta but not for branch vessels
  • Aortography
    • Gold standard
    • 25% have complications (i.e. infection & hematoma)
    • No longer routinely performed

Management

  • Management per ATLS for multiple injuries, hypotension
  • Initial medical management similar to Nontraumatic thoracic aortic dissection
  • Keep SBP <120, HR 60-80 with alpha/beta blockers, calcium-channel blockers
  • Type I injuries may be managed conservatively[3]
  • Surgical management for type II and greater

Disposition

  • Admission

See Also

References

  1. Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408
  2. Kram, H. B., Appel, P. L., Wohlmuth, D. A. and Shoemaker, W. C. (1989) ‘Diagnosis of traumatic thoracic aortic rupture: A 10-year retrospective analysis’, The Annals of Thoracic Surgery, 47(2), pp. 282–286
  3. Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408