Aortic Rupture

Injuries identified in the secondary survey require a further, indepth physical examination, upright chest film, arterial blood gas and EKG. Traumatic rupture of the aorta most commonly occurs just distal to the ligamentum arteriosum in the proximal descending thoracic aorta. It may range from a small intimal tear of the aorta to a full-blown complete transection with either exsanguinating hemorrhage or preservation of the patient's life by a column of peri-adventitial connective tissue, maintaining the continuity of the aortic lumen. Ninety percent of traumatic ruptures of the aorta are fatal at the time of the accident. Survivors of this event can usually be saved if the aortic rupture is identified expeditiously. Of the 10% who survive the aortic injury after the initial accident, one-half will die each day in the hospital if left untreated. Some of these patients may actually live for years with a traumatic transection of the aorta and not present until much later with a progressive false aneurysm. The radiologic findings of a traumatic transec-tion of the aorta includes blunting of the aortic knob, compression of the left mainstem bronchus, apical capping and widening of the mediastinum. Of these, widening of the mediastinum and blunting of the aortic knob are the two most sensitive indicators (Fig. 19.4a-b). It is important that if these two findings are identified on a supine chest x-ray, that an upright chest x-ray be obtained as well. In most cases, this simple maneuver will result in the appearance of a much narrower mediastinum and a sharp aortic knob. There may be cases of a deceptively sharp aortic knob appearing in aortic rupture (Fig. 19.5a-b). Index of suspicion and mechanism of injury alone may be sufficient indication for an aortogram. Another important radiologic finding is deviation of a nasogastric tube far to the right in patients with traumatic injuries to the aorta because of the large hematoma that develops in the left side of the mediastinum, shifting the mediastinum to right. A clinical finding is diminution of the left upper extremity blood pressure compared to the right upper extremity, resulting from compression of the left subclavian artery from hematoma. The management of these injuries is surgical, using single lung ventilation to collapse the lung, and dissection of the aorta with

Fig 19.2. Chest x-ray of a patient with a stab wound to the right ventricle in cardiac tamponade. The cardiac silhouette is not enlarged. The patient underwent successful repair of the injury.

Fig 19.3. Chest x-ray of a patient in tamponade from blunt avulsion of the inferior vena cava from the right atrium. The patient arrested and required subxiphoid decompression of the tamponade in the ER. Sternotomy and "sucker bypass" to the femoral artery permitted successful repair of the injury. Courtesy Dr. Michael Janusz, University British Columbia

clamping proximal to the injury between the left subclavian and left common carotid, clamping of the left subclavian, and clamping inferiorly. A primary repair is achieved by placing an interposition graft between the fractured segments (Fig. 19.6a-b). Spinal protection methods include femoral-femoral bypass, or left atrial-femoral arterial bypass. In general, a clamp and go method is feasible if done within 20-25 minutes and usually does not result in paraplegia.

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