Updated: 1/8/2020

Traumatic Aortic Disruption

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Snapshot
  • A 25-year-old man presents to the emergency department after a high-speed motor vehicle accident. He was the driver in the accident and was wearing his seatbelt. The patient reports chest pain with breathing difficulty. Vital signs are significant for a blood pressure of 137/95 mmHg and a pulse of 108/min. On physical exam, the patient is stable with a seatbelt and steering wheel imprint on the skin of his chest. An anteroposterior radiograph of the chest demonstrates an obscured aortic knob and widened mediastinum. Preparations are made to get a contrast-enhanced CT scan of the chest and trauma surgery is consulted. 
Introduction
  • Definition
    • blunt thoracic aortic injury
  • Pathophysiology
    • typically results from rapid deceleration, which is seen in
      • high-speed motor vehicle accidents (majority of cases)
      • falls from a significant height
  • Anatomy
    • aortic isthmus (most commonly affected)
      • distal to the left subclavian artery
      • this is the transition zone of a relatively more mobile ascending aorta and arch to the descending thoracic aortic, which is relatively fixed
Presentation
  • Symptoms
    • chest pain
    • intrascapular pain
    • breathing difficulty or swallowing
  • Physical exam
    • steering wheel or seatbelt imprint on the skin surface
    • left subclavian hematoma
    • new interscapular murmur
    • may find
      • pseudocoarctation (upper extremity hypertension)
      • absent bilateral femoral pulses
Imaging
  • Plain anteroposterior chest radiograph
    • indication
      • initial imaging of choice
    • findings
      • widened mediastinum  
      • abnormal aortic arch contour
      • abnormal aortic knob
      • tracheal deviation
  • Tracheoesophageal echocardiography
    • indication
      • in hemodynamically unstable patients
  • Contrast-enhanced chest CT
    • indication
      • in hemodynamically stable patients 
Treatment
  • Operative
    • aortic repair
      • indication
        • definitive treatment

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Questions (3)
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(M2.CV.16.4686) A 40-year-old unrestrained passenger is brought into the emergency room after a motor vehicle collision. The patient is awake and alert, though he complains of chest and back pain. Soon after he is brought in, the patient loses consciousness. His vitals are: Temperature 96 deg F (35.6 deg C), pulse 120/min, blood pressure 80/45 mmHg, and respirations 22/min. His physical exam is significant for bruising on his chest along with crepitus present with sternal palpation. His chest radiograph is shown in Figure A. Which of the following is the best next step for this patient?

QID: 107370
FIGURES:
1

Transthoracic echocardiogram along with fluids and blood products

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(0/6)

2

Transesophageal echocardiogram along with fluids and blood products

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(0/6)

3

CT angiogram along fluids and blood products

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(0/6)

4

CT scan along with fluids and blood products

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(0/6)

5

Immediate surgical intervention along with fluids and blood products

100%

(6/6)

M 6 E

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