Radiographic manifestations of mediastinal hemorrhage from blunt chest trauma

Early Clinical Diagnosis and Treatment of Traumatic Aortic Injury Caused by Thoracic and Abdominal Injuries: A Series of Four Cases with Literature Review

Aortic injury, particularly traumatic aortic dissection caused by thoracic and abdominal injuries, is extremely rare. The diagnosis rate of blunt aortic injury caused by chest and abdominal injuries is often low, and its clinical manifestations are atypical. Once missed or misdiagnosed, the consequences are serious. Early diagnosis of traumatic aortic injury in complex thoracic and abdominal injuries is a key factor in reducing the mortality of trauma patients. Among all trauma patients treated in our department from December 2018 to December 2020, we diagnosed four cases of aortic injury, including three cases of aortic dissection and one case of intramural hematoma. Successful surgical treatment and clinical outcome were achieved in all four patients. We found that early diagnosis and surgical treatment can help to reduce the mortality of patients with traumatic aortic injury and improve the prognosis.

Traumatic aortic injury: Computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries

Blunt chest trauma related acute thoracic aortic injury (TAI) is a life-threatening condition that requires prompt diagnosis and appropriate management because of high mortality. Computed tomography angiography (CTA) is the imaging of choice for evaluation of patients with major chest trauma findings suspicious of TAI on chest radiography. This case series describes the CTA findings in four high-velocity incident survivors with associated TAIs, discusses the injury type and treatment, and reviews the literature.

Odynophagia after Cardiac Catheterization: A Rare Complication in the Presence of Aberrant Subclavian Artery

Background

Vascular complications from transradial cardiac catheterization are uncommon. Mediastinal hematoma is a rare complication with life-threatening potential. We present a case of a patient who underwent cardiac catheterization and subsequently experienced odynophagia from injury to an aberrant subclavian artery that led to a mediastinal hematoma. Case Report. A 59-year-old female with past medical history of coronary artery disease presented with complaints of angina and underwent a transradial cardiac catheterization. Immediately after the procedure, the patient complained of chest pain and odynophagia. EKG and echocardiogram were unremarkable, and a CT scan of the chest demonstrated an ill-defined fluid collection present in the superior mediastinum and an aberrant right subclavian artery. The patient was closely monitored in the Intensive Care Unit, and the patient remained hemodynamically stable throughout the admission. The patient was subsequently discharged home in good condition and did well on outpatient follow-up.

Conclusion

Vascular injuries associated with delivery of standard radial catheters in the subclavian artery are rare, with very few cases reported in the literature. We presented the case of a patient who had a previously unidentified right aberrant subclavian artery with a retroesophageal course which precipitated the hematoma and subsequently resulted in odynophagia despite an uncomplicated catheterization. This rare complication of a commonplace procedure necessitates prompt recognition, appropriate hemodynamic management, and possible repair of the injured vessel to appropriately manage a potentially life-threatening condition.

A Case of Traumatic Aortic Transection Presenting With Hemorrhagic Shock

BACKGROUND

Aortic transection, or aortic rupture, is a rare diagnosis in trauma patients and carries a high mortality.

CASE REPORT

We present the case of a 61-year-old man presenting to a Level I trauma center after being struck by a motor vehicle, found to have an aortic transection. He was initially hypotensive and resuscitated with blood products due to concern for hemorrhagic shock. Aortic injury was suspected after chest x-ray study demonstrated a widened mediastinum. Traumatic thoracic aortic transection with pseudoaneurysm was diagnosed on computed tomography of the aorta, and the patient was taken to the operating room for thoracic endovascular repair of the aorta. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diagnosis of aortic injury can be challenging, especially in trauma patients presenting with hypotension. Aortic injury must be suspected in patients presenting after a high-velocity mechanism injury. It is an uncommon cause of hemorrhagic shock in trauma patients and must be considered even if other traumatic injuries are identified, as it commonly occurs with other significant injuries. Although chest x-ray study can be useful, a negative chest x-ray study does not rule out aortic injury. Aortic injury is a time-sensitive diagnosis, and early identification is key to these patients surviving to receive definitive management in the operating room.

Chest pain while gardening: a Stanford type A dissection involving the aortic root extending into the iliac arteries—an uncommon and potentially catastrophic disease process

Background

An aortic dissection is an uncommon and potentially catastrophic disease process that carries with it a high morbidity and mortality. The inciting event is a tear in the intimal lining of the aorta. This allows passage of blood through the tear and into the aortic media, resulting in the creation of a false lumen.

Case presentation

We describe the case of a 71-year-old male with a history of hypertension that suffered a Stanford type A dissection with an intimal flap beginning at the level of the aortic root and extending into the bilateral iliac arteries. His clinical presentation was further complicated by shock, cardiac tamponade, severe coagulopathy, an ischemic right lower extremity, infarction of his thoracic spinal cord, and subacute infarcts secondary to malperfusion and embolic disease. Despite maximal intervention, the patient continued to clinically decline and ultimately died on day 5.

Conclusion

The clinical presentation of an acute aortic dissection is often atypical and mimics other common disease processes. The signs and symptoms largely depend on the extent of the aortic dissection and the presence or absence of malperfusion. With a mortality increasing by 1–2% for every hour until definitive treatment, early recognition and prompt operative intervention are crucial for patient survival.

Deceleration thoracic aortic ruptures in trauma center level I areas: a 6-year retrospective study

OBJECTIVES

This retrospective study aimed to analyze the trend of mortality due to thoracic aortic ruptures caused by deceleration injuries that occurred within the catchment area of Hradec Kralove University Hospital.

MATERIALS AND METHODS

The study sample comprised 175 patients who had sustained thoracic aortic ruptures caused by deceleration injuries and were transported to Hradec Kralove University Hospital in 2009-2014. The small proportion of patients enrolled in this retrospective study were diagnosed and treated at the emergency department (ED). However, the overwhelming majority of the sample comprised of patients who died at the accident scene and later underwent an autopsy at the Institute of Forensic Medicine in our hospital.

RESULTS

Of 175 patients, 150 underwent an autopsy. Of these, 139 individuals (79%) died at the incident scene, and 11 (6%) were transported to the ED and later died of their injuries. A total of 36 patients were admitted to the hospital; 29 were admitted primary (11 later died), and 7 were transferred. No deaths occurred in the group of secondary admissions. Thus, 31% of all patients hospitalized died following transport to the hospital. Of 175 patients, 15% (or 69% of all hospitalized patients) survived their injuries. Among patients who died as a result of thoracic aortic injury, no unexpected deaths were recorded (i.e., no deaths among patients with survival probability more than 50% = PS > 0.5).

CONCLUSION

Our results suggested that the lethality of thoracic aortic injuries might be minimized by transporting triage-positive patients directly to trauma centers. Accurate diagnoses and treatments were supported by admission chest X-rays, a massive transfusion protocol, and particularly, CT angiography, which is not routinely included in primary surveys. An additional prognostic parameter was clinical collaboration between an experienced trauma surgeon, an interventional radiologist, and a vascular or thoracic surgeon.

Chest Radiography in Acute Traumatic Rupture of the Thoracic Aorta

Of 123 patients who had suffered blunt trauma to the chest traumatic aortic rupture was eventually confirmed in 61 and absent in 62 patients. The chest radiographs of these patients were examined for 15 signs reported in the literature as being associated with traumatic aortic rupture. Although many individual signs were significantly more frequent in the aortic rupture group they were not useful in differentiating between patients with and those without rupture of the aorta. By using discriminant analysis combining 2 or 3 signs, patients were classified as having aortic rupture or not. The best discrimination between the two groups was obtained using the combined signs of a widened paratracheal stripe, an opacified pulmonary window, a widened right paraspinal interface and a displaced nasogastric tube.

Acute traumatic aortic injury: practical considerations for the diagnostic radiologist

The diagnosis of acute traumatic aortic injury (ATAI) relies heavily on accurate and efficient imaging interpretation, thereby making the radiologist integral to the care of patients in whom these life-threatening lesions are suspected. Typically, this evaluation begins with the initial trauma radiograph, in which findings suggestive of mediastinal hematoma or ATAI can be detected. Definitive diagnosis of ATAI is made with the current gold standard, computed tomography, wherein indirect and direct signs of ATAI provide the means for sensitive and specific diagnosis. Although the diagnosis of ATAI on computed tomography can be straightforward, technical and anatomic pitfalls can complicate interpretation and must be understood. Once the diagnosis is made, the radiologist needs to provide a meaningful report that includes an appropriate description of the lesion location and characteristics. The purpose of this article is to review the key aspects of the imaging evaluation of ATAI with a focus on factors that affect the management of these patients.

Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection

We aimed to explore the diagnostic accuracy of various mediastinal measurements in determining acute nontraumatic thoracic aortic dissection with respect to posteroanterior (PA) and anteroposterior (AP) chest radiographs, which had received little attention so far. We retrospectively reviewed 100 patients (50 PA and 50 AP chest radiographs) with confirmed acute thoracic aortic dissection and 120 patients (60 PA and 60 AP chest radiographs) with confirmed normal aorta. Those who had prior history of trauma or aortic disease were excluded. The maximal mediastinal width (MW) and maximal left mediastinal width (LMW) were measured by two independent radiologists and the mediastinal width ratio (MWR) was calculated. Statistical analysis was then performed with independent sample t test. PA projection was significantly more accurate than AP projection, achieving higher sensitivity and specificity. LMW and MW were the most powerful parameters on PA and AP chest radiographs, respectively. The optimal cutoff levels were LMW = 4.95 cm (sensitivity, 90 %; specificity, 90 %) and MW = 7.45 cm (sensitivity, 90 %; specificity, 88.3 %) for PA projection and LMW = 5.45 cm (sensitivity, 76 %; specificity, 65 %) and MW = 8.65 cm (sensitivity, 72 %; specificity, 80 %) for AP projection. MWR was found less useful and less reliable. The use of LMW alone in PA film would allow more accurate prediction of aortic dissection. PA chest radiograph has a higher diagnostic accuracy when compared with AP chest radiograph, with negative PA chest radiograph showing less probability for aortic dissection. Lower threshold for proceeding to computed tomography aortogram is recommended however, especially in the elderly and patients with widened mediastinum on AP chest radiograph.

Mediastinal hematomas: aortic injury and beyond

Mediastinal hematomas are the end result of numerous conditions ranging from the deadly traumatic aortic injury to the common changes after open heart surgery. The location of the hematoma, its relation with the surrounding structures, the clinical history, and associated findings can help narrow the differential diagnosis. Contrast-enhanced computed tomography is the imaging modality of choice because of its accessibility, noninvasiveness, rapid acquisition, and ability to evaluate the entire thorax at once.

Acute traumatic aortic injury: imaging evaluation and management

Despite recent advances in prehospital care, multidetector computed tomographic (CT) technology, and rapid definitive therapy, trauma to the aorta continues to be a substantial source of morbidity and mortality in patients with blunt trauma. The imaging evaluation of acute aortic injuries has undergone radical change over the past decade, mostly due to the advent of multidetector CT. Regardless of recent technologic advances, imaging of the aorta in the trauma setting remains a multimodality imaging practice, and thus broad knowledge by the radiologist is essential. Likewise, the therapy for acute aortic injuries has changed substantially. Though open surgical repair continues to be the mainstay of therapy, percutaneous endovascular repair is becoming commonplace in many trauma centers. Here, the historical and current status of imaging and therapy of acute traumatic aortic injuries will be reviewed.

Diagnosis of blunt traumatic aortic injury 2007: still a nemesis

In recent years, the use of multidetector computed tomography (MDCT) for the diagnosis of acute thoracic injury in blunt trauma has expanded. MDCT has shown high accuracy for the diagnosis or exclusion of injury to the aorta and its primary branches, decreasing the need for thoracic angiography and allowing earlier treatment of this often rapidly fatal lesion. With increasing use of MDCT, more subtle injuries and variants of vascular anatomy are being recognized that create pitfalls in the diagnosis. Of perhaps more concern is the recognition that aortic injury can occur with little or no associated mediastinal hematoma, the principle chest radiographic finding indicating a need for further imaging. The importance of recognizing unusual sites of aortic injury, congenital variants of mediastinal anatomy, the precise extent of injury, and the anatomic pathology present as key factors in deciding among treatment options is emphasized.

Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with "normal" chest radiograph?

BACKGROUND

A major cause of morbidity and mortality after blunt chest trauma remains undetected injuries. This study evaluates the role of routine computed tomographic (CT) scan.

METHODS

We studied 93 consecutive patients from January 1999 to July 2000: 73 (76.3%) after motor vehicle crash with crash speed > 10 mph, and 22 (23.7%) after fall from height > 5 ft. Simultaneous with initial clinical evaluation, anteroposterior chest radiograph and helical chest CT scan were obtained for all patients.

RESULTS

Sixty-eight patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion.

CONCLUSION

Over 50% of patients with normal initial chest radiograph showed multiple injuries on the CT scan, among which were also two (8%) potentially fatal aortic lesions. We therefore recommend primary routine chest CT scan in all patients with major chest trauma.

Chest Radiographs of Limited Utility in the Diagnosis of Blunt Traumatic Aortic Laceration

BACKGROUND

The radiographic diagnosis of blunt traumatic aortic laceration (BTAL) remains problematic. We reviewed our experience with chest radiographic signs of BTAL at a single trauma center.

METHODS

The chest radiographs of 188 consecutive blunt trauma patients with suspected BTAL who underwent portable chest radiography and aortography were retrospectively reviewed by a thoracic radiologist. The presence or absence of 15 radiographic findings were recorded, and the sensitivity and specificity of individual radiographic signs and combinations of signs were determined.

RESULTS

There were 10 patients with BTAL. Although three signs showed greater than 90% sensitivity for BTAL, these signs showed low specificity, and no significant improvement in overall accuracy was achieved by combining radiographic findings.

CONCLUSION

The experience at our institution suggests that chest radiographs have limited utility in the accurate diagnosis of blunt traumatic aortic laceration. Cross-sectional imaging techniques will likely become the preferred imaging procedures for evaluating patients with suspected BTAL.

The surgeon's use of transesophageal echocardiography

Transesophageal echocardiography has become an instrumental diagnostic modality for the accurate evaluation of cardiac and aortic anatomy and function. Multiplanar technology has facilitated improved visualization of structures and enhanced TEE over TTE in many situations. Care of the trauma patient and critically ill patient is improved with the appropriate and timely performance of TEE. Education, certification, credentialing, and determination of competency are areas that need to be addressed continually in the future.

Traumatic disruption of the thoracic aorta: a rational approach to imaging

An imaging strategy is crucial in patients who have sustained a traumatic disruption of the thoracic aorta. Of those who reach hospital alive, 70-90 per cent will survive if diagnosed early and treated appropriately. The clinician has many imaging techniques to choose from, but they vary considerably in their degree of accuracy and performance time. Consequently their appropriateness is dependent on the type of injury suspected, the haemodynamic stability of the patient and the availability and experience of the radiologists. This article describes the types and presentation of traumatic thoracic aortic disruption so that the advantages and disadvantages of the various imaging modalities can be explained. It concludes by presenting an imaging strategy for use when this condition is suspected.

Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma

OBJECTIVE

To assess the diagnostic potential of transthoracic and transoesophageal echocardiography for the detection of traumatic cardiovascular injuries in patients suffering from severe blunt chest trauma.

DESIGN

Prospective study over a three year period.

SETTING

A regional cardiothoracic centre.

PATIENTS

134 consecutive patients (94 M/40 F; mean age 38 (SD 14) years) suffering from severe blunt chest trauma (injury severity score 33.5 (18.2)). Most patients (89%) were victims of motor vehicle accidents.

EVALUATION

All patients underwent transthoracic and transoesophageal echocardiography within 8 h of admission. Aortography was performed in the first 20 patients and in a further five equivocal cases.

RESULTS

Transthoracic echocardiography provided suboptimal images in 83 patients, detecting three aortic ruptures, 28 pericardial effusions (one cardiac tamponade), 35 left pleural effusions, and 15 myocardial contusions. Transoesophageal echocardiography was feasible in 131 patients and detected 14 aortic ruptures (13 at the isthmus), 40 pericardial effusions, 51 left pleural effusions, 34 periaortic haematomas, 45 myocardial contusions, right atrial laceration in one patient with cardiac tamponade, one tricuspid valve rupture, and one severe mitral regurgitation caused by annular disruption. For the detection of aortic rupture transoesophageal echocardiography showed 93% sensitivity, 98% specificity, and 98% accuracy. Time to surgery was significantly shorter (30 (12) v 71 (21) min; P < 0.05) for patients operated on only on the basis of transoesophageal echocardiographic findings.

CONCLUSIONS

Transthoracic echocardiography has low diagnostic yield in severe blunt chest trauma, while transoesophageal echocardiography provides accurate diagnosis in a short time at the bedside, is inexpensive, minimally invasive, and does not interfere with other diagnostic or therapeutic procedures.

Transesophageal echocardiography for the initial evaluation of the widened mediastinum in trauma patients

Traumatic disruption of the thoracic aorta is an injury that is rapidly fatal if not recognized and treated early. Increasingly, transesophageal echocardiography (TEE) is being used to evaluate the thoracic aorta after trauma with reported sensitivity and specificity rates of up to 100%. To confirm these results, we instituted a protocol using TEE as the initial diagnostic study for excluding a ruptured thoracic aorta in patients with widened mediastinum. All TEE studies were done by experienced cardiologists; 96% were done in the trauma receiving area. TEE studies were classified as positive, negative, or indeterminant. Indeterminant studies were those in which the diagnosis of aortic injury could not be excluded based solely on TEE findings. Because we were interested in using TEE as a "definitive" diagnostic modality, indeterminant studies were regarded as positive for our analysis. This protocol was used in 114 trauma patients over a 3-year period. TEE identified five thoracic aortic disruptions--three confirmed by aortography and two by thoracotomy. TEE was read as indeterminant in 17 patients and further investigation with aortography showed no aortic injury in these patients. TEE was negative in 89 patients who had no further evaluation and were subsequently discharged or who died from other injuries. TEE failed to reveal significant lesions in three patients who had aortograms that revealed disruptions requiring thoracotomy. The use of TEE for the definitive diagnosis of ruptured aorta in this series yields a sensitivity of 63% and a specificity of 84%.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiography in the evaluation of thoracic trauma

Echocardiography has become a useful diagnostic modality in the evaluation of cardiovascular injury after thoracic trauma. Valuable information about cardiac wall motion, valvular function, pericardial effusions, and ventricular volume status can be obtained without significant risk. More recent application for the diagnosis of traumatic aortic disruption provides a safer, easier, less expensive, and more accurate method for detecting these injuries. Cardiac evaluation with TTE is unsuccessful in approximately 20% of examinations and is unable to provide the image resolution of the more invasive transesophageal approach.

Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta

BACKGROUND

Rupture of the aorta is a major cause of death after motor vehicle accidents. Survival depends on early diagnosis, and emergency aortography is the standard imaging method. Although transesophageal echocardiography is noninvasive and can provide high-resolution images of the aorta, information about its value in patients with trauma is limited. We conducted this study to assess prospectively the value of transesophageal echocardiography in the emergency evaluation of patients at risk for aortic injury.

METHODS

Transesophageal echocardiography of the aorta was attempted in 101 patients admitted to the emergency room with a diagnosis of possible traumatic rupture of the aorta. Echocardiography and aortography personnel were notified simultaneously of the arrival of the patient, and the two tests were performed sequentially by operators who were blinded to the results of the other test. The sensitivity and specificity of transesophageal echocardiography were calculated on the basis of the results of aortography of the arch, surgery, or autopsy.

RESULTS

Transesophageal echocardiography was attempted in 101 patients. The study was successfully performed in 93 patients but could not be completed in 8 because of lack of cooperation on the part of the patient (7 patients) or maxillofacial trauma (1 patient). Despite a high injury-severity score (mean, 29.6), transesophageal echocardiography was performed without complications, and within a mean (+/- SD) of 29 +/- 12 minutes. Eleven of the 93 studies (12 percent) demonstrated rupture of the aorta near the isthmus. The findings were confirmed in 10 of the 11 patients by aortography (9 patients), surgery (9 patients), or autopsy (1 patient), yielding a sensitivity of 100 percent and specificity of 98 percent for the detection of injury to the aorta. There was one false positive echocardiogram.

CONCLUSIONS

Transesophageal echocardiography is a highly sensitive and specific method of detecting injury to the thoracic aorta. This technique can be used safely and quickly in critically injured patients with suspected traumatic rupture of the aorta and compares favorably with arch aortography.

Computed tomography as a screening exam in patients with suspected blunt aortic injury

BACKGROUND

Chest computed tomography (CT) screening of patients with blunt trauma for thoracic aortic injury is controversial. This study was undertaken to determine whether CT could exclude aortic injury and be used to select patients for aortography.

METHODS

Computed tomography and aortography were used to evaluate 155 patients with blunt trauma. Computed tomography scans were reviewed separately by four attending radiologists who were unaware of the patients' clinical course and angiographic findings.

RESULTS

Eight of 155 patients had aortic injuries requiring operation. Computed tomography scans in five patients were read as positive by all reviewers. One scan was read as positive by three reviewers and as negative by one. Two scans were read as positive by two radiologists and as negative by two. After poor scans were excluded, the combined sensitivity of CT for detecting aortic injury was 88%, specificity was 54%, positive predictive value was 9%, and negative predictive value 99%.

CONCLUSIONS

The sensitivity of CT scan for indicating the need for aortography is observer dependent. As CT manifestations of aortic injury are often subtle, CT does not reliably exclude aortic injury.

Blunt injuries to the innominate artery

Two patients with aneurysm secondary to blunt traumatic subadventitial rupture of the distal innominate artery (IA) are reported. IA rupture was identified because of a cervical bruit in one patient and detected during thoracic aortography in the other patient. The patients had associated cardiovascular lesions consisting of traumatic aneurysm of the subclavian artery and rupture of the aortic valve, respectively. Both lesions were surgically repaired by resection of the lacerated intima and direct closure of the adventitia. In the patient who underwent repair of the aortic valve with simultaneous cardiopulmonary bypass the IA was approached after cannulation of the right common carotid artery. In the other patient the IA was repaired without use of a shunt under close EEG monitoring. Injury to the IA is rare because the artery is short and relatively well protected by the bony cage. Other cardiovascular lesions may be associated with IA rupture and a routine search should be made.

Traumatic aortic injuries: current concepts

This article summarizes current concepts of traumatic injuries of the aorta. The "osseous pinch" mechanism of injury is presented and discussed. The role of each imaging modality in patient evaluation is considered and a rational approach to their use suggested based on current technology and practices.

Use of CT for diagnosis of traumatic rupture of the thoracic aorta

CT imaging of traumatic aortic rupture has been both advocated and disparaged in the current literature as a reliable diagnostic modality. In a retrospective review of blunt chest trauma patients at our institution evaluated by both thoracic CT and arteriography, we found a 17% false negative rate and a 39% false positive rate. Although we feel CT is not sufficiently sensitive at present to evaluate traumatic rupture of the aorta directly, it is an invaluable adjunctive imaging modality for stable blunt chest trauma patients with equivocal chest radiographs or arteriograms.

Routine initial computed tomography of the chest in blunt torso trauma

Computer tomography (CT) is an effective technique in the initial evaluation of the abdomen and head following blunt trauma. To evaluate the role of CT of the thorax, a prospective study comparing routine early thoracic CT scanning with initial chest roentgenogram (CXR) was carried out on 73 patients with blunt torso trauma undergoing concomitant abdominal CT examination. Initial CXR and CT scans were interpreted independently by radiologists in a blinded fashion. CXR diagnosed more bony injuries than CT, while the CT identified pulmonary contusions and effusions more accurately. Only those contusions diagnosed by CXR proved clinically significant. Patient treatment was changed in one case based on CT findings. In the absence of CXR findings, chest CT scanning frequently identifies abnormalities with limited clinical significance. Although more sensitive, CT of the thorax has a limited role in the initial emergent evaluation of victims of blunt torso trauma.

Prediction of traumatic aortic rupture from plain chest film findings using stepwise logistic regression

We reviewed initial chest radiographs of 21 patients with, and 26 without, aortic rupture, and examined the presence or absence of individual signs previously cited to be associated with aortic rupture. Using stepwise logistic regression, the three most significant signs associated with rupture were loss of aortic contour, tracheal deviation, and mediastinal-to-chest ratio. A formula calculating the probability of aortic rupture (P) using these three variables was derived. Using a low cutoff point, this equation would approach 100% sensitivity in detecting aortic rupture while reducing the number of negative aortographs. The reliability of this equation and the optimal cutoff point must be determined in a prospective study before being used to make clinical decisions.

Mediastinal hematoma mimicking aortic rupture

The case of a child who fell a relatively short distance and had clinical and x-ray findings consistent with a ruptured aorta is presented. At surgery, a mediastinal hematoma was found. Diagnostic and therapeutic implications are discussed.

Transection of the thoracic aorta: assessment of a trauma system

A large, heavily populated area regionalized the care of critical trauma in 1980. To evaluate the system, we reviewed patient outcome for thoracic aortic transection due to blunt injury for the first 18 months of trauma system operation. Of the total of 86 patients, 43 were transferred to trauma centers, 8 to nontrauma centers, and 35 were either directly transported to the coroner or dead on arrival at the hospital. Of the eight patients transported to non-trauma centers, seven were in cardiopulmonary arrest during transport and the eighth was pronounced dead shortly after admission to the emergency department. Twenty-seven of the 43 patients transferred to trauma centers were dead within 24 minutes of admission. The cause of death was rupture of a transected aorta in 22 patients and other multiple injuries in the remaining 5. Sixteen were alive long enough in the emergency department for evaluation. Nine of these patients underwent correction of aortic transection as well as other injuries and all survived. Two of the nine survivors sustained partial or complete spinal cord damage. The remaining seven patients died, but in only one patient did the undiagnosed aortic injury contribute to the cause of death. This patient had a normal cineangiogram and the diagnosis was made at autopsy. He was considered potentially salvageable, so 9 of 10 potentially salvageable patients survived (90 percent). Of the total of 86 patients with aortic transection, 77 died (90 percent). This study shows that regionalization of trauma care offers an excellent chance for survival of patients with thoracic aortic transection.

Management of injuries of the thoracic and abdominal aorta

Thirty-five patients had surgery for injuries of the aorta at the Los Angeles County-USC Medical Center over a 4 1/2 year period. There were 27 survivors. The principles of management were to operate without delay if there was evidence of continued bleeding after initial fluid replacement as occurred in 11 patients. For the 24 patients who became stable after initial resuscitation, a more deliberate plan of management was used. Blood pressure was carefully monitored and controlled to avoid hypertension. Priorities for associated injuries were established and in several cases, they took treatment precedence over the aortic injury. Delay was sometimes necessary to utilize the more experienced personnel. In no instance did a stabilized patient hemorrhage during the delay. The most common injury seen was a blunt disruption of the proximal descending aorta. The details of the operative technique for this injury have been reported herein, along with a justification for not using either pump bypass or shunt to perfuse the distal aorta during the period of aortic cross-clamping.