2. OUTLINE
Definition and classification
Brief anatomy and pathophysiology of the
chest
Recognize the types and mechanisms of
life threatening thoracic injuries
Initial assessment and mx of various
thoracic injuries
Secondary mx of thoracic injuries and
some unique challenges they can impose
11. Epidemiology
A third of RTA’s have significant chest trauma
Approx. 80% is blunt chest trauma
20 - 25% overall mortality
Majority of the deaths are preventable
< 10% of BCT require surgical intervention as
opposed to 15 - 30% in PCT
12. CLINICAL PRESENTATION
VARIED
Polytraumatized with other injury
components i.e. abdominal hemorrhage
MECHANISM OF INJURY
HIGH INDEX OF SUSPICION FOR
SINISTER BADNESS BENEATH
THE SURFACE
21. Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial
Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD,
PhD; Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD
Arch Surg. 1999;134:186-189.
22. Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial
Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD, PhD;
Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD
Arch Surg. 1999;134:186-189.
23. OPEN PNEUMOTHORAX
“Sucking” chest wound
Respiratory distress
Preferential path of air
when hole ≥ ⅔ diameter
of trachea
Cover 3 sides
EMERGENCY ICC
INSERTION
36. Rationale for EDT
Resus agonal pt with PCT
Evacuation of pericardial tamponade
Control intra-thoracic hemorrhage
X-clamp to DTA
X-clamp the hilum of the lung
Perform open CPR
Repair cardiac injuries
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
37. FORMIDABLE
UNDERTAKING
Uncontrolled set up
Iatrogenic injury from sharps
Transmission of communicable diseases
HIV, HEPATITIS
DISTRACTING e.g requires significant
resources
38.
39. Eastern Association For the
Surgery of Trauma Guidelines
(EAST)
Patient manifest signs of life in the field or the
hospital
Patient has PCT and is hemodynamically unstable
despite appropriate fluid resuscitation OR has
required CPR for < 15 mins
A thoracic or trauma surgeon is available within 45
mins
40. SIGNS OF LIFE
Spontaneous
breathing
Palpable carotid
pulse
Measurable BP
Electrical cardiac
activity
Pupillary light
response
Spontaneous
extremity movement
41. Contra-indications for EDT
NO PULSE OR BP IN THE FIELD
ASYSTOLE AND NO PERICARDIAL TAMPONADE
CPR > 15mins
MASSIVE NON SURVIVABLE INJURIES
NO THORACIC OR TRAUMA SURGEON WITHIN
45 mins
53. Immediate Life Threatening Thoracic
Injuries: Aortic Disruption
Occurs commonly @
Ligamentum
arteriosum
≅ ⅓ fatality on site
due to free rupture
Exsanguination
Rapid acceleration-
deceleration ( i.e.
MVA, falls from height
> 3m)
54. Contained Injuries to the Aorta
Widened mediastinum
Obliteration of aortic knob
Right deviation of trachea
Depression of LMS bronchus
Pleural/apical cap
Left hemothorax (can be
bilateral)
Fractures of 1st and/or 2nd
ribs
56. Contained Injuries to the Aorta
Not a source of multiple
hypotensive episodes in
survivors - look for other
injuries
Salvageable tear when
hematoma contained
~⅓ die per 24 hours
without treatment
Widened mediastinum
very unreliable sign on
portable x-ray
TEE, helical contrast CT
scan, MRI, aortogram
TEVAR
Address after life
threatening injuries
stabilized
57. POST TRAUMATIC
PNEUMOTHORAX
≥ 15% OF THE THORAX
Intercostal tube drain
Eighty percent of chest trauma including
PCT managed by ICC
59. Significant morbidity and even mortality
Poor pain control
Underlying lung disease
Elderly
Atelectasis PneumoniaRespiratory
failure
Thromboembolism
60. Flail chest
3 or more adjacent
ribs # @ 2 or more
places
Cautious fluid resus.
Analgesia
EVOLVING
PULMONARY
CONTUSIONS
61. SURGICAL FIXATION vs
CONSERVATIVE MX
PAIN CONTROL
VENTILATORY
REQUIREMENTS
SHORTER ICU & HOSPITAL STAY
IMPROVED POST-OP RESP
FUNCTION
62. STERNAL FRACTURES
Significant impacting force
MVA with steering wheel impact or
seat belt injury
UNDERLYING CARDIAC CONTUSION
CXR, e-FAST, ECG and serial troponin
71. Summary
Life ending thoracic injuries are common
Survival depends on proper and
immediate diagnosis and appropriate
management
ED thoracotomy can save lives but
expected survivorship is <10%
Don’t forget ABC’s of trauma and
damage control principles
Editor's Notes
There are 4 major objectives to this module:
The first is to understand that statistics of the epidemiology and incidence of thoracic injuries in the US
The second objective is to recognize that there are various types of thoracic injuries that are a function of the nature and mechanism of the inflicting agent. We will cover thoracic trauma divided into sub-categories of blunt trauma – which can be further divided into deceleration injury such as sustained in falls and MVA and penetrating trauma which is sub-divided by injuring agent also into GSW and stab wounds.
The third objective is to comprehend the initial assessment and management of thoracic injuries with a special understanding that there are unique problems associated with thoracic trauma that is different from abdominal trauma and the cause of similar hemodynamic parameters can be different with thoracic injuries.
The fourth objective is to understand secondary management of the various thoracic injuries with a special emphasis on imaging, work-up and definitive surgery.
Classified into 2 broad groups depending on wheter a breach in the thoracic wall has occurred with involvement of intrathoracic structures
Injuries that breach the chest wall may impact the body with significant amount of energy which can result in localized damage along the wound tract or significant dissipation of disruptive forces to surrounding through the cavitation effect producing remote injuries. It might also be the result of a change in trajectory due to impact on other structures. So sometimes what you see on the surface belies real badness beneath. One of the pitfalls in the management of people with this kind of condition. An awareness and high index suspicion must always guide mx in this pts.. Geography and society play a role in determining the pattern we see and what predominates ie war torn areas, violent societies GSW and chilled out places MVA, footy injuries
Suspect in any victim with penetrating wound, neck or upper abdomen. Particularly dangerous site is the central chest area from clavicles xiphisternum / between right nipple and left lateral chest wall (described as the ‘danger box’)
Can be seen in blunt trauma in patients on anticoagulants or antithrombotic drugs
Immediate deaths are usually due to major disruption of the heart or of great vessels. Early deaths due to thoracic trauma occurring within 30 minutes to 3 hours after the injury are usually secondary to cardiac tamponade, airway obstruction and aspiration, or rupture of thoracic aortic tears that have been temporarily contained. Two thirds of these patients reach the hospital prior to death. Only 10-15% of blunt trauma require thoracic surgery, and 15-30% of the penetrating chest trauma require open thoracotomy. Overall, about 85% of patients with thoracic trauma can be managed without surgical treatment.
The evaluation of the patient's chest trauma is only a part of the total assessment and the basic ABC’s of the primary survey and resuscitation cannot be overlooked. It is important to keep several special factors in mind when dealing with a patient with potential thoracic injuries because thoracic injuries are severe and potentially lethal and the diagnosis and therapy go hand in hand as there can be unique mechanical factors that cause the alterations in vital signs. Injuries such as tension pneumothorax can be rapidly fatal if missed but treated and cured in a matter of moments when recognized.
In unstable and critical patients quick decisions based on check of the following vital signs are required. Airway patency: in the initial survey is mandatory to control the airway patency. Patency of the airway does not necessarily assure adequate ventilation in patients with chest injuries unless the airway is in continuity with the lungs. Patients may be ventilated without oxygenating their blood with chest injuries due to pulmonary contusions or airway disruption. All the airway manipulations must be performed with respect to potential cervical spinal injuries. Breathing: in order to know if patient is breathing is necessary to check respiratory movement, and their extension which can be compromised by chest wall integrity. Cyanosis appears very late in hypoxia due to a thoracic trauma because in shocky patients the skin blood flow depends on blood redistribution in the body. Circulation: the state of the circulation is evaluated by assessing patient's pulses (radial, carotid or femoral). The blood pressure is evaluated by width of pulse. In hypovolemic shock radial pulse becomes small; may be absent when blood pressure is below 60 mm/Hg. In thoracic trauma is important to assess the neck veins that are flat in hypovolemia are distended when there is cardiac tamponade. But if cardiac tamponade is associated with hypovolemic shock distension of the neck veins may be absent. Thoracic cavity is constituted from two structures: the first, rigid, comprehending the rib cage, clavicle, sternum, scapula and the second comprehending respiratory muscles. Adequate ventilation and oxygenation depends on an intact chest wall. Significant injury with fracture and muscular disruption may allow direct injury to the underlying lungs, heart, great vessels and upper abdominal viscera. In addition, respiration may be seriously impaired by effective or paradoxical motion of a portion of the thoracic cage (as in flail chest) and the result is respiratory insufficiency.
This is a list of the immediate causes of death following chest injuries. Each will be discussed in more detail on the following slides.
Identifying cardiac tamponade vs. tension pneumothorax is a critical differential diagnosis that must be made accurately and almost instantaneously since both are treatable and curable injuries. Both present with low or absent blood pressure (PEA) but the physiology is opposite since tamponade is due to compression of the right heart and tension pneumothorax is due to absent filling of the right heart. The major differentials relate to etiology – the neck veins are distended in tamponade since blood is trying to enter the heart and cant and flat in tension pneumothorax since there is no blood in the right heart. An important pitfall in this differential finding is that in hypovolemic patients neck veins can be flat in both injuries. Cardiac tones are usually muffled in tamponade but this can be difficult to appreciate in the noisy trauma areas and breath sounds are usually absent on the affected side in tension pneumothorax but this can also be had to hear. Generally patients are very tachypnic when alert with a tension pneumothorax but patients in shock are all tachypnic so this can also be an unreliable indicator. Both can be worsened by positive pressure ventilation since both are functions of right heart physiology and the treatment for both is a needle – one into the chest the other into the pericardium. The use of e-FAST might be helpful
Lung collapse, Hemi-diaphragmatic depression, Increased separation of ribs, Increased thoracic volume Loss of lung markings, Possibly reduced heart sounds?)
Massive hemothorax is common in both penetrating and blunt chest injuries. Patients who sustain acute hemothorax are at risk for hemodynamic instability due to loss of intravascular volume and compromised central venous return due to increased intrathoracic pressure. Lung compression due to massive blood accumulation may also cause respiratory compromise. Sources of hemothorax are: lung, intercostal vessels, internal mammary artery, thoracicoacromial artery, lateral thoracic artery, mediastinal great vessels, heart, abdominal structures (liver, spleen) when diaphragmatic hernia. The diagnosis is readily made from the clinical picture and X-ray evidence of fluid in the pleural space. Primary thoracentesis is carried out to confirm the diagnosis. Optimal therapy consists of the placement of a large (36 French) chest tube. A moderate size hemothorax (500-1500 ml) that stops bleeding after thoracostomy can generally be treated by closed drainage alone. However, a hemothorax of greater than 1500 to 2000 ml as with continued bleeding of more than 100 to 200 ml per hour is an indication for emergency thoracotomy or thoracoscopy. A small percentage of hemothoraces proceed to clot and cannot be evacuated by thoracentesis. Massive clots may lead to respiratory difficulty and infection, and should be evacuated surgically. Small clots will probably be resorbed and do not require operative removal.
Hemothorax is common in both penetrating and non-penetrating injures to the chest. If the hemorrhage is severe, it may not only cause hypovolemic shock but also dangerously reduces vital capacity by compressing the lung on the involved side. Persistent hemorrhage usually arises from an intercostal or internal thoracic (internal mammary) artery and less frequently from the major hylar vessels. Bleeding from the lung generally stops within a few minutes, although initially it may be profuse. In some cases hemothorax may come from a wound of the heart or from abdominal structures such as the liver or spleen if the diaphragm has been lacerated. Hypovolemic shock and hemomediastinum can derive from a thoracic great vessels injury that may be result of penetrating or blunt trauma. The most common etiology is penetrating trauma; however, the descending thoracic aorta, the innominate artery, the pulmonary veins, and the vena cavae are susceptible to rupture for blunt trauma.
An open pneumothorax occurs when there is a pneumothorax associated with a chest wall defect, such that the pneumothorax communicates with the exterior.
During inspiration, when a negative intra-thoracic pressure is generated, air is entrained into the chest cavity not through the trachea but through the hole in the chest wall. This is because the chest wall defect is much shorter than the trachea, and hence provides less resistance to flow. Once the size of the hole is more than 0.75 times the size of the trachea, air preferentially enters through the thoracic cavity.
This results in inadequate oxygenation and ventilation, and a progressive build-up of air in the pleural space. The pneumothorax may tension if a flap has been created that allows air in, but not out.
Diagnosis should be made clinically during the primary survey. A wound in the chest wall is identified that appears to be 'sucking air' into the chest and may be visibly bubbling - this is diagnostic.
Breathing is rapid, shallow and laboured. There is reduced expansion of the hemithorax, accompanied by reduced breath sounds and an increased percussion note. One or all of these signs may not be appreciated in the noisy trauma room.
100% oxygen should be delivered via a facemask. Consideration should be given to intubation where oxygenation or ventilation is inadequate. Intubation should not delay placement of a chest tube and closure of the wound.
The definitive management of the open pneumothorax is to place an occlusive dressing over the wound and immediately place an intercostal chest drain.
Rarely, if a chest drain is not available and the patient is far from a definitive care facility, a bandage may be applied over the wound and taped on 3 sides. This, in theory, acts as a flap-valve to allow air to escape from the pneumothorax during expiration, but not to enter during inspiration. This dressing may be difficult to apply to a large wound and it's effect is very variable. As soon as possible a chest drain should be placed and the wound closed.
Most tracheal injuries are cervical and range from crush injuries to compete tracheal separation.
Can be missed on CXR usually a massive emphysema in the neck and chest wall and even sub-diaphragmatic regions
Only 50% of patients will have a pneumothorax with this injury, and hemothorax is uncommon Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the first month·
If endotracheal intubation is not possible, a surgical airway should be obtained Primary repair of tracheal lacerations or separation should be performed, if possible Blunt trauma typically causes a circumferential laceration of either main bronchus with complete separation Early repair is the preferred treatment if the diagnosis is made, and requires thoracotomy with intubation of the uninjured bronchus
Late strictures from incomplete tears or parenchymal isolation from complete tears can be repaired with bronchoplastic procedures, but may require pulmonary resection.
Laryngotracheal injuries constitute only a small fraction of admissions in a major trauma centre. The frequency has been reported to be as low as 0.3 percent. However, mortality is reported as high as 24 percent. Complete disruption of trachea is amongst the rarest injuries with only a few cases reported in literature. Seuvre (cited by Papamicheal is credited with the first description of traumatic tracheal disruption. Direct blows are more likely to be associated with fractures of cartilaginous frame work of the larynx(7). The signs and symptoms are often subtle even in complete transections of trachea. The two ends may be held in close approximation by peritracheal connective tissue and soft tissues of the neck.
Clinical features include subcutaneous surgical emphysema, pneumothorax, respiratory distress, hemoptysis and loss of palpable landmarks8. Most of these features were present in our cases except pneumothorax which was seen only in the first case. The signs and symptoms are non specific and correlate poorly with the severity of the underlying injury(9). Therefore, a high degree of suspicion and a more aggressive approach towards diagnosis and management is required as delayed treatment may prove fatal as in our second case.
Neck and chest radiographs though essential cannot be completely relied upon. CT scan or MRI if available can give accurate diagnosis, otherwise direct laryngoscopy and bronchoscopy can be utilized to confirm the diagnosis as delay leads to a poor prognosis.
Management includes, tracheostomy and early surgical repair. The best results are obtained with a complete repair of the larynx and trachea with end to end anastomosis of disrupted trachea which avoids a permanent tracheostomy and patient retains a good voice. The second best option is a permanent tracheostomy which means a loss of voice.
Most tracheal injuries are cervical and range from crush injuries to compete tracheal separation · If endotracheal intubation is not possible, a surgical airway should be obtained · Primary repair of tracheal lacerations or separation should be performed, if possible · Blunt trauma typically causes a circumferential laceration of either main bronchus with complete separation · Only 50% of patients will have a pneumothorax with this injury, and hemothorax is uncommon · Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the first month · Early repair is the preferred treatment if the diagnosis is made, and requires thoracotomy with intubation of the uninjured bronchus · Late strictures from incomplete tears or parenchymal isolation from complete tears can be repaired with bronchoplastic procedures, but may require pulmonary resection.
Laryngotracheal injuries constitute only a small fraction of admissions in a major trauma centre. The frequency has been reported to be as low as 0.3 percent. However, mortality is reported as high as 24 percent. Complete disruption of trachea is amongst the rarest injuries with only a few cases reported in literature. Seuvre (cited by Papamicheal is credited with the first description of traumatic tracheal disruption. Direct blows are more likely to be associated with fractures of cartilaginous frame work of the larynx(7). The signs and symptoms are often subtle even in complete transections of trachea. The two ends may be held in close approximation by peritracheal connective tissue and soft tissues of the neck.
Clinical features include subcutaneous surgical emphysema, pneumothorax, respiratory distress, hemoptysis and loss of palpable landmarks8. Most of these features were present in our cases except pneumothorax which was seen only in the first case. The signs and symptoms are non specific and correlate poorly with the severity of the underlying injury(9). Therefore, a high degree of suspicion and a more aggressive approach towards diagnosis and management is required as delayed treatment may prove fatal as in our second case.
Neck and chest radiographs though essential cannot be completely relied upon. CT scan or MRI if available can give accurate diagnosis, otherwise direct laryngoscopy and bronchoscopy can be utilized to confirm the diagnosis as delay leads to a poor prognosis.
Management includes, tracheostomy and early surgical repair. The best results are obtained with a complete repair of the larynx and trachea with end to end anastomosis of disrupted trachea which avoids a permanent tracheostomy and patient retains a good voice. The second best option is a permanent tracheostomy which means a loss of voice.
Cardiac tamponade is usually due to penetrating cardiac injuries and is a leading cause of trauma death in urban areas.
Patients with penetrating wounds of the heart can be classified in 3 general groups:
1. patients who have received extensive lacerations or large-caliber gunshot wounds, that die almost immediately, as a result of rapid and voluminous blood loss
2. patient with small wounds of the heart, caused by ice picks, knives or other small agents who because of the development of cardiac tamponade, reach the hospital alive. Cardiac tamponade, by bringing pressure to bear on the bleeding heart wall, also plays an important role in controlling the hemorrhage;
3. patient with associated serious injuries in the chest and/or elsewhere in the body which, in themselves, may contribute to death.
The condition of the patient, when he is admitted to the hospital, must not be used as an index of the severity of the injury. There are moribund patients with no blood pressure and nonperceptible pulse, who survive operation and recover; on the other hand there are patients in fair condition, with a systolic blood pressure ranging from 70 mmHg to normal and fair-to-good pulse, who die before surgery. The immediate cause of death is either exanguination, cardiac tamponade or interference with the conduction mechanism. Diagnosis generally is easy if the physician maintains a high degree of suspicion of heart injury in every chest wound he encounters. The safest approach is to remove the patient's clothing and survey the entire body surface quickly for evidence of multiple injuries. Auscultation of the thorax is performed specifically to evaluate the clarity of heart tones and breath sounds. Muffled heart tones are an indication of blood in the pericardium. A systolic - to diastolic gradient of less then 30 mmHg, associated with hypotension is consistent with cardiac tamponade. Neck veins are distended. Central venous pressure is elevated. The X-ray film may demonstrate a widening of the cardiac silhouette. The ultrasound scan shows presence of blood in pericardial space. Electrocardiograph is not particularly helpful. Prompt definitive therapy is imperative. This includes antishock therapy, pericardiocentesis (possibly under U.S. guide), emergency thoracotomy and suture of the wound.
Treat with VOLUME immediately to raise the CVP greater than the intrapericardial pressure and shock trousers then proceed with percutaneous and ultimately surgical decompression of the pericardium.
Cardiac tamponade requires prompt recognition and treatment. Signs and symptoms range from rarely stable to Beck’s triad of hypotension, CVP above 12cc of water and muffled heart sounds – all three findings are present in fewer than 40% of patients with tamponade. An elevated CVP is the most significant diagnostic finding. Only 60ml of haemopericardium is necessary for a tamponade to occur in adults. A vicious cycle is set in motion i.e.
↓ LVEDV → ↓ S.V. → ↓ CO → compensatory tachycardia → ↑ cardiac work → ↑ O2 demand → hypoxia and lactic acidosis.
An enlarged cardiac silhouette on CXR and / pericardial effusion as demonstrated by echocardiography help to confirm the clinical suspicion and diagnosis.
Using aseptic technique, Insert at least 3” needle at the angle of the Xiphoid Cartilage at the 7th rib
Advance needle at 45 degree towards the lt shoulder while aspirating syringe till blood return is seen
Continue to Aspirate till syringe is full then discard blood and attempt again till signs of no more blood
Closely monitor patient due to small amout of blood aspirated can cause a rapid change in blood pressure
Indicated to resuscitate trauma patients who have sustained a witnessed arrest or are on the verge of a cardiac arrest.
It allows for both diagnosis and treatment, it provides direct access to the heart, lungs and great vessels enabling effective resus ie evacuation of pleural and pericardial collections. Open cardiac massage and cross clamping of the hilar or descending aorta. It also facilitates repair cardiac injuries
Survival data suggest it is better in those patients with penetrating injury preferably with isolated stab injury who show signs of life @ presentation in the event of deterioration they should have very brief period of CPR with SR/PEA
Up to 15% of all deaths following motor vehicle collisions are due to injury to the thoracic aorta. Many of these patients are dead at scene from complete aortic transection. Patients who survive to the emergency department usually have small tears or partial-thickness tears of the aortic wall with pseudoaneurysm formation.
Most blunt aortic injuries occur in the proximal thoracic aorta, although any portion of the aorta is at risk. The proximal descending aorta, where the relatively mobile aortic arch can move against the fixed descending aorta (ligamentum arteriousm), is at greatest risk from the shearing forces of sudden deceleration. Thus the aorta is a greatest risk in frontal or side impacts, and falls from heights. Other postulated mechanisms for aortic injury are compression between the sternum and the spine, and sudden increases in intra-luminal aortic pressure at the moment of impact.
On CXR look for these signs but they are VERY unreliable on a portable AP CXR and diagnosis requires a high index of suspicion often based on nature of injury.
Mediastinal width of more than 8cm at the level of the aortic arch is considered abnormal and an indication for further imaging.
A widened mediastinum is reported as having a 53% sensitivity, 59% specificity and 83% negative predictive value for traumatic aortic injury.
To maintain spinal precautions in blunt trauma patients, most AP chest radiographs are taken in the supine position.
This will lead to fluid shifts that may cause a widened mediastinum. Some authors recommend repeating the radiograph with the patient erect
if the spine can be cleared prior to this. Around 40% of widened mediastinums will 'normalize' with the patient in the erect position.
Other less sensitive signs of mediastinal great vessel injury include depression of the left main-stem bronchus, deviation of the naso-gastric tube to the right,
apical pleural haemoatoma (cap), disruption of the calcium ring in the aortic knob (broken-halo).
None of these 'classic' signs have any useful sensitivity to use them as a screening for blunt aortic injury.
Thus the 'funny-looking' mediastinum remains the best indicator of the need for further imaging and should be examined with these other findings to judge the risk of aortic injury:
Widened mediastinum (least reliable)
Obliteration of aortic knob
Rightward deviation of trachea
Rightward deviation of esophagus (look for NG tube)
Depression of left main stem bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd rib(s)
On CT scan the diagnosis is correct 97% of the time look for peri-aortic hematoma, pleural effusions and aortography is correct in about 97-98% of the time.
On CT scan the diagnosis is correct 97% of the time look for peri-aortic hematoma, pleural effusions and aortography is correct in about 97-98% of the time.
Most blunt aortic injuries surviving to hospital are partial-transections, and should be managed with blood pressure control until the defintivie repair. Thus the priority in the management of hemodynamically unstable patients with potential aortic injury is to rapidly identify and control on-going hemorrhage from other sites, and to avoid over-resuscitation. Sites of concealed hemorrhage are identified with Chest and Pelvis radiographs and FAST ultrasound or Diagnostic Peritoneal Lavage.
The caveat to these cases is the patient with and aortic tear and impending rupture. These patients classically present as 'meta-stable' - ie they respond to fluid resuscitation and then drop their blood pressure in a cyclical manner. It is important to recognize this futile cycle early and avoid aggressive cyclical resuscitation, as this will ultimately lead to free rupture of the aorta and an iatrogenic hypothermia & coagulopathy. Beware the 'meta-stable' patient with a widened mediastinum and a left-sided hemothorax!
May not be initially obvious in young adult where muscles splint the fractured ribs; in these situations paradoxical movement will be apparent only if the victim becomes exhausted, the flail is large (>6 ribs) or is central (involving sternum).
Intercostal blocks, epidural analgaesia and opioid / ketamine infusions or patient-controlled analgaesia should be considered later during the secondary survey, depending on the expertise available. Some patients require tracheal intubation and controlled ventilation.
