Today, during the morning handover, there was a polytrauma case. Very interesting, since he has thoracic aorta dissection,, open book fracture of pelvis, liver laceration and fracture femur. Another striking findings were rhabdomyolysis and acute kidney injury. This is a very interesting case since there are a few possible causes of acute kidney injury which include hypovolemia, contrast induced nephropathy, rhabdomyolisis, and trauma to the genitourinary tract.
I asked the MO, was the dissection due to blunt aortic injury?? Well, she didn't have a clue.
Blunt aortic injury usually occur at the junction between the mobile arch and the fixed descending aorta, just distal to the origin of the left subclavian artery, as a result of severe deceleration injury. Less frequently, the ascending aorta or arch vessels are injured by direct trauma.
It is divided into two:
1. Significant aortic injury: with disruption of the intima and full thickness of the media. There is a high risk of rupture
2. Minimal aortic injury: with laceration limited to the intima and inner media. Radiologically this manifests as an intimal flap< 1 cm with minimal periaortic hematoma. There is a low risk of rupture
Clinical signs include unequal upper limb pulses, pseudocoarctation or interscapular murmur. The aortic injury should be suspected if the mechanism of injury is suggestive of rapid deceleration such as high speed (greater than 90 km/hr) motor vehicle or motorcycle crashes or a pedestrian hit by a vehicle.
CT and transesophageal echocardiography have been used for screening and diagnostic purposes.
Limitation of TOE : it provides high diagnostic accuracy for aortic injury and also allows examination for blunt cardiac injury. Imaging of distal aorta, proximal arch and major branches are limited.
Chest radiograph signs of blunt aortic injury:
1. Signs of periaortic hematoma:
-Widened mediastinum > 8 cm at the level of aortic knuckle
-Obscured aortic knuckle
-Opacification of aortopulmonary window
-Deviation of trachea, left main bronchus or nasogastric tube
-Thickened paratracheal stripe
2. Indirect signs:
-left haemothorax
-Left pleural cap
-Fractured first or second ribs
Significant aortic injury requires prompt surgical or endoluminal stent repair. Surgery should be deferred sometimes indefinitely if severe associated injuries or comorbidities make the operative risk unacceptably high.
Options for surgery: direct repair (clamp and sew), endoluminal stent repair.
Conservative management includes antihypertensive therapy (B-blockers +/- vasodilators) and serial imaging to assess for expanding pseudoaneurysm that will require intervention.
reference: Oh's intensive care manual 5th edition pg 794
I asked the MO, was the dissection due to blunt aortic injury?? Well, she didn't have a clue.
Blunt aortic injury usually occur at the junction between the mobile arch and the fixed descending aorta, just distal to the origin of the left subclavian artery, as a result of severe deceleration injury. Less frequently, the ascending aorta or arch vessels are injured by direct trauma.
It is divided into two:
1. Significant aortic injury: with disruption of the intima and full thickness of the media. There is a high risk of rupture
2. Minimal aortic injury: with laceration limited to the intima and inner media. Radiologically this manifests as an intimal flap< 1 cm with minimal periaortic hematoma. There is a low risk of rupture
Clinical signs include unequal upper limb pulses, pseudocoarctation or interscapular murmur. The aortic injury should be suspected if the mechanism of injury is suggestive of rapid deceleration such as high speed (greater than 90 km/hr) motor vehicle or motorcycle crashes or a pedestrian hit by a vehicle.
CT and transesophageal echocardiography have been used for screening and diagnostic purposes.
Limitation of TOE : it provides high diagnostic accuracy for aortic injury and also allows examination for blunt cardiac injury. Imaging of distal aorta, proximal arch and major branches are limited.
Chest radiograph signs of blunt aortic injury:
1. Signs of periaortic hematoma:
-Widened mediastinum > 8 cm at the level of aortic knuckle
-Obscured aortic knuckle
-Opacification of aortopulmonary window
-Deviation of trachea, left main bronchus or nasogastric tube
-Thickened paratracheal stripe
2. Indirect signs:
-left haemothorax
-Left pleural cap
-Fractured first or second ribs
Significant aortic injury requires prompt surgical or endoluminal stent repair. Surgery should be deferred sometimes indefinitely if severe associated injuries or comorbidities make the operative risk unacceptably high.
Options for surgery: direct repair (clamp and sew), endoluminal stent repair.
Conservative management includes antihypertensive therapy (B-blockers +/- vasodilators) and serial imaging to assess for expanding pseudoaneurysm that will require intervention.
reference: Oh's intensive care manual 5th edition pg 794
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