Episode 929: Traumatic Aortic Injury

11/04/24 • 5 min

2 Listeners

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

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
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
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
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
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

Donate: https://emergencymedicalminute.org/donate/

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

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
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
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
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
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

Donate: https://emergencymedicalminute.org/donate/

Previous Episode

Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

There is a big disparity between Cape Town and its neighbor Khayelitsha.
Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.
Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.
This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.
Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

Medical education in South Africa typically follows a 6-year undergraduate program directly after high school
Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.
Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.
Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.
Fever is common in appendicitis (~40%) and becomes less common with older patients.
Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.
Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.
Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.
Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.
Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.
Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Next Episode

Episode 930: Holding Costs

Contributor: Aaron Lessen MD

Educational Pearls:

A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue

Prospective, observational study of acute stroke management
Conducted at a large urban, comprehensive stroke center

The study evaluated patients in multiple categories:

admitted to med/surg
admitted to med/surg but held in the ED
admitted to the ICU
Admitted to ICU but held in the ED

Examined the amount of time nurses and providers spent with each patient

This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED

Conclusions:

Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost

$1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care

Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large

$2267 for ICU inpatient boarding vs $2165 for ICU care

Holding in the ED negatively impacts patients since they receive less time from providers
Holding also results in increased financial costs

References

Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/