Traumatic aortic transection: Difference between revisions
No edit summary |
|||
(3 intermediate revisions by 2 users not shown) | |||
Line 1: | Line 1: | ||
''Not to be confused with [[nontraumatic thoracic aortic dissection]]'' | ''Not to be confused with [[nontraumatic thoracic aortic dissection]]'' | ||
==Background== | ==Background== | ||
[[File:Aorta segments.jpg|thumb|Aortic sebments.]] | |||
[[File:Aorta branches.jpg|thumb|Branches of the aorta.]] | |||
[[File:PMC3443276 13244 2012 187 Fig22 HTML.png|thumb|Aortic isthmus laceration with pseudoaneurysm (arrow), mediastinal hematoma, and bilateral hemothorax]] | [[File:PMC3443276 13244 2012 187 Fig22 HTML.png|thumb|Aortic isthmus laceration with pseudoaneurysm (arrow), mediastinal hematoma, and bilateral hemothorax]] | ||
*Blunt traumatic mechanism, rapid deceleration | *Blunt traumatic mechanism, rapid deceleration | ||
Line 41: | Line 42: | ||
**Diagnostic study of choice | **Diagnostic study of choice | ||
**Good for aorta but not for branch vessels | **Good for aorta but not for branch vessels | ||
*[[CXR]] | *[[CXR]] (may be an initial screening study, but is not sensitive) | ||
**Widened mediastinum (>8cm on supine film) | **Widened mediastinum (>8cm on supine film) | ||
**Left apical cap | **Left apical cap | ||
Line 57: | Line 57: | ||
===Diagnosis=== | ===Diagnosis=== | ||
===Classification<ref>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</ref>=== | ====Classification<ref>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</ref>==== | ||
[[File:PMC4330229 13244 2014 380 Fig1 HTML.png|thumb|(a) Grade 1: Intimal flaps at the level of the proximal descending aorta and 10 cm distal to the subclavian artery (arrowheads) with accompanying mediastinal hematoma. (b) Grade 3: large pseudoaneurysm formation. (c) and (d) Traumatic aortic transection (grade 4) with massive para-aortic hematoma.]] | [[File:PMC4330229 13244 2014 380 Fig1 HTML.png|thumb|(a) Grade 1: Intimal flaps at the level of the proximal descending aorta and 10 cm distal to the subclavian artery (arrowheads) with accompanying mediastinal hematoma. (b) Grade 3: large pseudoaneurysm formation. (c) and (d) Traumatic aortic transection (grade 4) with massive para-aortic hematoma.]] | ||
''Based on CT findings'' | ''Based on CT findings'' | ||
Line 68: | Line 68: | ||
*Management per [[ATLS]] for multiple injuries, hypotension | *Management per [[ATLS]] for multiple injuries, hypotension | ||
*Initial medical management similar to [[Nontraumatic thoracic aortic dissection]] | *Initial medical management similar to [[Nontraumatic thoracic aortic dissection]] | ||
*Keep SBP <120, HR 60-80 with α/β-blockers, calcium-channel blockers | *Keep SBP <120, HR 60-80 with α/[[beta blockers|β-blockers]], [[calcium-channel blockers]] | ||
*Type I injuries may be managed conservatively<ref>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</ref> | *Type I injuries may be managed conservatively<ref>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</ref> | ||
*Surgical management for type II and greater | *Surgical management for type II and greater |
Latest revision as of 20:36, 5 May 2021
Not to be confused with nontraumatic thoracic aortic dissection
Background
- Blunt traumatic mechanism, rapid deceleration
- Most common location is isthmus (90%) just distal to the left subclavian artery[1]
- Where the ligamentum arteriosum tethers the aorta and pulmonary artery
- Other locations are:
- Ascending aorta (5%)
- Diaphragmatic hiatus (5%)
- Often asymptomatic but die without warning (80% die at scene)
- Do NOT have Hypotension (just die, but may have initial hypertension in upper extremities)
- Need high suspicion to diagnose
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 if isolated traumatic aortic transection
- Aortic hematoma stretches sympathetic fibers, increasing systemic vascular resistance
- Patients either have moderately elevated BP or no blood pressure at all, as true rupture leads quickly to death
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
Workup
- CT
- Diagnostic study of choice
- Good for aorta but not for branch vessels
- CXR (may be an initial screening study, but is not sensitive)
- Widened mediastinum (>8cm on supine film)
- Left apical cap
- Enlarged aortic knob
- Left hemothorax
- Rightward tracheal/esophageal deviation
- Depression of left mainstem bronchus
- Elevation of right mainstem bronchus
- Widened paratracheal stripe
- Widened paraspinal interfaces
- Aortography
- No longer routinely performed, although previously the gold standard
- 25% have complications (i.e. infection & hematoma)
Diagnosis
Classification[3]
Based on CT findings
- Type I: Intimal tear
- Type II: Intramural hematoma
- Type III: Pseudoaneurysm
- Type IV: Rupture (free rupture, periaortic hematoma)
Management
- Management per ATLS for multiple injuries, hypotension
- Initial medical management similar to Nontraumatic thoracic aortic dissection
- Keep SBP <120, HR 60-80 with α/β-blockers, calcium-channel blockers
- Type I injuries may be managed conservatively[4]
- Surgical management for type II and greater
Disposition
- Admission
See Also
References
- ↑ Wojciechowski J et al. Traumatic aortic injury: does the anatomy of the aortic arch influence aortic trauma severity? Nov 2016. Surg Today. 2017; 47(3): 328–334.
- ↑ 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
- ↑ 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
- ↑ 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