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

Diagnosis

  • CXR
    • Widened mediastinum(>8cm on supine film)
    • Left apical cap
    • Enlarged aortic knob
    • Left hemothorax
    • Rightward tracheal deviation
  • 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

Treatment

  • Management per ATLS for multiple injuries, hypotension
  • Initial medical management similar to Nontraumatic thoracic aortic dissection
  • Keep SBP <120, HR 60-80 w/ alpha/beta blockers, CCBs
  • 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
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