Blunt Aortic Injury

• Caused by high acceleration/deceleration

• e.g. MVA, MCA, ped vs. auto

• CXR

• Suspicion if:

• widened mediastinum (although only present in 2/3 of cases)

• Indistinct aortic knob (21%)

• ¼ of cases have normal CXRs

Associated injuries

• Closed head – 39%

• Closed head w/ bleed – 22%

• Rib fxs – 68%

• Lung contusion – 42%

• Pelvic fx – 34%

• Femur fx – 25%

• Tibial fx – 25%

• Facial fx – 25%

• Liver – 25%

• Spleen – 13%

Diagnosis

• Gold standard historically aortography

• Newer evidence supports use of CT angiogram

• Very sensitive

• But more false positives

Diagnosis

• Advantages of CT over aortography:

• 1) easier, faster, less invasive, less expensive

• 2) pts likely to get CTs for other injuries

• 3) reconstructions can be made

• 4) CT may be better at dx # & extent of injuries

CT angio

• One prospective study evaluated 8000+ CTs for blunt torso trauma over 4 years

• 494 had mediastinal hematoma, or aortic injury, or both on CT

• 71 dx w/ aortic injury

• MVA 92%, ped vs. auto 4%, MCA 3%

• 71% male

• Incidence in MVA – 1.2%

CT angio

• Sensitivity 100%, Specificity 83%, Positive Predictive Valve 50%

• Aortogram: 92%, 99%, 97%

• Therefore only need aortogram if CT is positive or indeterminate

• this decreased # of aortograms by 66%

Areas most-likely injured

• Where aorta is fixed

• Isthmus – 86%

• Arch – 7%

• Diaphragm – 7%

• Ascending – 1%

CT findings

• Intimal flap

• Minor – 39%

• Moderate – 30%

• Severe – 30%

• Pseudoaneurysm

• Absent – 12%

• Small – 20%

• Medium – 13%

• Large – 55%

Comparison of survivors to non-survivors

• Age

• 36 vs. 47 (p value=0.02)

• Injury severity score

• 31 vs. 39 (p value=0.01)

• Glascow coma scale

• 14 vs. 8 (p value=0.0001)

Treatment

• Immediate operative repair

• Delayed operative repair after medically optimized

• Medical management alone

Operative repair

• Immediate repair if hemodynamically unstable

• Delayed repair if hemodynamically stable & pt has other major injuries

• closed head injury, lung injury, abd injury, etc.

• Close f/u to determine if clinically significant

Medical management

• Use of anti-hypertensives first described at MGH

• Successful in mgt of dissecting aortic aneurysms -> reducing shearing forces

Medical management

• Beta blockers

• labetalol, esmolol

• Vasodilators if BP not controllable w/ B blockers alone

• Nitroprusside

• One study showed 0/71 ruptures w/ early dx and rx

Endovascular vs. Open repair?

• In one study EV repair had decreased mortality, morbidity & ICU length of stay compared to open repair

• Mortality 0% vs. 17%

• Paraplegia 0% vs. 16%

• Recurrent laryngeal nerve injury 0% vs. 8%

This post was written by: Franklin Manuel

Franklin Manuel is a professional blogger, web designer and front end web developer. Follow him on Twitter