Episode 929: Traumatic Aortic Injury

Emergency Medical Minute

Contributor: Aaron Lessen MD

Educational Pearls:

• Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma

• Majority are caused by automobile collisions or motorcycle accidents

• Due to sudden deceleration mechanism accidents

• Clinical manifestations

• Signs of hypovolemic shock including tachycardia and hypotension, though not always present

• Patients may have altered mental status

• Imaging

• Widened mediastinum on chest x-ray, though not highly sensitive

• CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities

• In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used

• Four types of aortic injury (in order of ascending severity)

• I: Intimal tear or flap

• II: Intramural hematoma

• III: Pseudoaneurysm

• IV: Rupture

• Management

• Hemodynamically unstable: immediate OR for exploratory laparotomy and repair

• Hemodynamically stable: heart rate and blood pressure control with beta-blockers

• Minor injuries are treated with observation and hemodynamic control

• Severe injuries may receive surgical management

• Some patients benefit from delayed repair

• An endovascular aortic graft is a surgical option

• Mortality

• 80-85% of patients die before hospital arrival

• 50% of patients that make it to the hospital do not survive

References

1. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470

2. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027

3. Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007

4. Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003

5. Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416

Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit

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