Outcome of blunt thoracic aortic injury in a level I trauma center: an 8-year review

BACKGROUND: The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome. METHODS: Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed. RESULTS: Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors in group 3 (n = 12) were significantly higher than survivors. There were no significant differences when comparing time of injury to repair or arrival between groups, or in mortality or paralysis comparing repair techniques or clamp/bypass times. Double lumen endotracheal tubes caused significant operative delays compared to single lumen tubes. CONCLUSIONS: Predictors of survivability were hemodynamic stability on arrival and lower Injury Severity Scores. In thoracic aortic injury patients arriving hemodynamically stable, Injury Severity Score correlated with mortality but not paralysis.     

A case of complete circumferential aortic rupture due to blunt chest trauma

A case of complete circumferential rupture of the thoracic aorta due to blunt chest trauma is presented. A 30-year-old man was admitted after a traffic accident. The admission chest X-ray film demonstrated mediastinal widening. About 6 hours after the traffic accident, chest CT scanning demonstrated mediastinal hematoma, left pleural effusion and partial aortic dissection. Diagnoses of aortic rupture and liver injury were made, and surgery for the thoracic aorta was performed immediately. The aorta was found to be completely disrupted for the length of 2 cm, and a vascular prosthesis was interposed between the two ends of the aorta under partial cardiopulmonary bypass. We conclude that the enhanced chest CT scanning is helpful for diagnosis, and that if other organ injuries are not severe, the emergency operation should be performed.     

Right coronary artery dissection and acute infarction due to blunt trauma: report of a case

Coronary artery dissection occurring after a nonpenetrating chest trauma is extremely rare. We describe herein the case of a 43-year-old man who suffered traumatic myocardial infarction after an intimal tear of the right coronary artery had been inflicted by a horse stepping on his back.     

Occlusive arterial disease of the hand due to repetitive blunt trauma: a review with illustrative cases

OBJECTIVE: to increase clinical awareness of the role of repetitive blunt trauma, often occupational, in the development of occlusive arterial disease of the hand. STUDY DESIGN: illustrative cases are presented to emphasize the varied etiology and clinical features of occlusive arterial disease of the hand resulting from repetitive blunt trauma and an historical review of the literature is presented. RESULTS: Occlusive arterial disease of the hand due to repetitive blunt trauma is a common but often preventable disorder. The superficial location of many of the arteries of the hands and digits plus their close proximity to the bones of the hand makes them uniquely susceptible to injury from repetitive blunt trauma. An ever increasing number of occupations and leisure activities have been causally related to occlusive arterial disease of the hand. The diagnosis of occupational occlusive arterial disease due to blunt trauma is suggested by eliciting a history of repetitive blunt trauma to the hand in a patient with symptoms and/or signs of digital ischemia. The dominant hand is most commonly involved, but the non-dominant hand or both hands are affected in certain occupations. Possible predisposing or aggravating factors include tobacco use and working in a cold environment. The diagnosis of occlusive arterial disease confined to the hand or digits is confirmed by non-invasive studies in the vascular laboratory and demonstrated by arteriography. Conservative measures and protection of the hand from further trauma is sufficient for most patients, with surgical therapy being reserved for patients refractory to medical therapy or those with more severe ischemia. CONCLUSION: occlusive arterial disease of the hand may be more common than formerly thought and is often preventable by the proper use of hand tools or instruments and hand protection. This is another type of occlusive arterial disease in which tobacco may be a predisposing or aggravating factor.     

Tracheobronchial injuries in blunt thoracic trauma

Tracheobronchial lesions after blunt chest injury are seldom (0,5-0,7%). Diagnostic and therapeutic strategies in 16 own cases and a review of the literature are presented. Own experiences: Locations of the lesions were main bronchus (10), bronchus intermedius (2), and trachea (4). Rupture was total in five cases, and partial in seven. In four patients the mucosa only was ruptured. Initial symptoms: Subcutaneous emphysema (13), pneumothorax (9), respiratory insufficiency (5), lung lesion (5), but tracheal bleeding in five cases only. Diagnosis mainly by bronchoscopy (8 early, 4 late), but in 4 cases after thoracotomy. Treatment: In cases of total rupture, there were three anastomoses of the bronchus and one of the trachea, and one pneumonectomy. In all partial ruptures, there was suturing of the lesion. Mucosa lesions were treated conservatively. RESULTS: 1 empyema, 2 ex. leth. (bilateral pneumonia 7.d., multiple organ failure 20. d). FOLLOW UP: 9 patients free of symptoms, 5 patients with respiratory problems. The symptoms "mediastinal emphysema and continuous air leakage through the chest tube or persistent atelectasis of the lung" are indications for urgent bronchoscopy and early surgery. Long-term results are good in 70%-90% of the cases. Not diagnosed lesions can result in tracheobronchial stenosis and infections of the lung later on, to be treated by lung resection only. Total bronchial ruptures can result in strictures and non-infected atelectasis, resection of the stricture and reinflation of the lung being successful in 60%-70% of these late diagnosed cases.     

Successful repair of tricuspid regurgitation due to blunt trauma

A 19-year-old man developed paralysis of the left arm as a result of left brachial plexus injury by a traffic accident. He underwent operation for the brachial plexus paralysis, and then severe heart failure developed postoperatively. Echocardiography revealed severe tricuspid valve regurgitation. Tricuspid valve plasty was performed 14 months after the traffic accident. The anterior leaflet of the tricuspid valve was torn and the chordae attached there were torn as well. The torn anterior leaflet was sutured directly, and the prolapsed portion of this leaflet was collected by transfer of the elongated chordae. Annuloplasty (DeVega technique) was then added. Postoperative echocardiography revealed trivial regurgitation of the tricuspid valve. Only 9 cases of successful repair of traumatic tricuspid regurgitation have been reported in Japan.     

Heart injury due to blunt violence]

One case of non-penetrating injury of the heart is reported. The problem of the causal relation between accident and injury of the heart as well as the problems of the pathophysiological mechanisms of non-penetrating traumatic injury of the heart are discussed. The localisation of the non-penetrating traumatic injury, the volume and the energy of the object causing the injury as well as the preexisting degree of coronary sclerosis is of some importance for the severity of heart damages after non-penetrating traumatic injuries of the heart.     

Imaging of thoracic aortic dissection

Acute thoracic aortic dissection has a high mortality if untreated, so the diagnosis must be rapidly made if mortality is to be lowered significantly. Multiple imaging techniques are often used. This retrospective study from 1988 to 1993 assesses the usefulness in diagnosis of chest X-rays, computed tomography (CT) scanning, aortography, magnetic resonance imaging (MRI), trans-thoracic (TTE) and trans-oesophageal (TOE) echocardiography. Forty-two patients with a final clinical diagnosis of dissection were studied. The diagnosis was confirmed in 16 (13 at surgery and three at autopsy). Three died with dissection given as the only cause for death. Chest X-ray abnormalities were seen in all 19 patients with surgery or death from dissection, with a widened mediastinum and/or dilated aorta being present in 17. In the group of 16 patients with surgery or autopsy proof, CT scans found dissections in 9 of 12 patients studied and correctly classified the type in only five. Aortography was performed in five, with accurate depiction of dissection and type in all. TTE found dissections in three of eight patients imaged by this method. MRI and TOE were performed each on two patients, with accurate depiction of dissection and type in each. Because of the relatively low sensitivity of CT scanning in defining aortic dissections Westmead Hospital is currently assessing the use of TOE as the prime imaging modality prior to surgical intervention.     

Severe laryngeal injury caused by blunt trauma to the neck: a case report

Acute blunt laryngeal trauma can be a life-threatening event and often poses a difficult airway management problem. Patients may be unable to supply important anemnestic facts because of aphonia or intubation as a result of their injury. Therefore the immediate recognition and appropriate initial assessment and treatment are vital for a successful outcome. The first step is assuring an appropriate airway, either by careful intubation or temporary tracheotomy. An assessment of potential vascular and oesophageal injuries must be undertaken. The use of computerized tomography (CT) with contrast material is especially useful in identifying and localizing the damage caused by blunt neck injuries. Laryngeal fractures, air in the soft tissues and the extravasation of contrast material in the neck are all helpful in assessing the injuries before surgical intervention. Immediate initial surgery is aimed at stabilizing the cartilaginous framework and repairing the mucosa. We present a case of severe laryngeal injury caused by blunt trauma to the neck; our evaluation, treatment and the outcome.     

Hollow visceral injury and blunt trauma

BACKGROUND: The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis. METHODS: A 9-year trauma registry review of all patients with HVI. RESULTS: A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05). CONCLUSION: HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.     

Computed tomography in duodenal rupture due to blunt abdominal trauma

Computed tomography (CT) has become a useful procedure in the evaluation of abdominal trauma, since it is able to detect abnormalities in contour or tissue density of the major abdominal and retroperitoneal organs and spaces. Cases have been reported demonstrating the usefulness of CT in evaluating splenic, renal, and hepatic hematomas, retroperitoneal hemorrhage, spinal injuries, and traumatic diaphragmatic hernia. We describe a patient with traumatic rupture of the duodenum in whom CT played a key role in the diagnosis.     

Laparoscopy in the management of diaphragmatic rupture due to blunt trauma

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH2O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH2O), reimplantation with bladder augmentation is recommended.     

Aortoventricular fistula secondary to blunt trauma: a case report and review of the literature

An aorto-right ventricular fistula secondary to nonpenetrating trauma is described. Review of the literature is reported. Ascending aortic injuries present as either traumatic pseudoaneurysms or, less commonly, as aortocardiac fistulas. Blunt cardiac injury is a frequent concomitant injury and contributes to the high mortality of this lesion. Prompt surgical intervention is required for survival.     

Surgical treatment of aortic rupture by blunt chest trauma

During a ten-year period, seven patients with traumatic rupture of the thoracic aorta were operated upon. Four patients of them were operated within one week. Chest X-rays and chest computed tomography could not always reveal the exact diagnosis of aortic rupture. Intravenous digital subtraction angiography was useful to confirm the diagnosis. The repair of the rupture was accomplished with the adjunct of left heart bypass using Bio-pump, which was useful to reduce the bloodloss with a limited systemic heparinization. Another three patients were diagnosed to have chronic post-traumatic aneurysm of the thoracic aorta and underwent aortic replacement with prosthetic graft. One of seven patients died at seventh postoperative day because of cerebral contusion, the associated lesion of an automobile accident. It is stated that the aortic rupture is immediately fatal in approximately 80% of individuals, and most of remaining 20% die within 2 weeks unless the lesion is repaired. Therefore immediate operative intervention is recommended when the aortic rupture is strongly suspected. Chronic post-traumatic aneurysms should be resected because it has become apparent that the majority of patients with this lesion will develop complication, such as sudden rupture.     

Rare electrocution due to powerline contact in a hot-air balloon: comparison with fatalities from blunt trauma

Powerline contact by hot-air balloons is one of the most frequent concurrences in balloon accidents resulting in injury or death. Injuries and deaths are usually a result of blunt trauma from falls. In this report, we describe the aircraft, the circumstances of the accidents and the autopsy data in two powerline contact accidents involving three deaths, one from electrocution and two, from blunt trauma sustained in falls. Appropriate pilot behavior is briefly discussed.     

Important radiologic findings following blunt thoracic trauma (author's transl)

In patients suffering from traffic accidents traumatic lesions of the chest are of special importance since in 50% of deaths the thoracic trauma is responsible for the final outcome. The fatal course is, however, not always due to severe and irreparable dammage to thoracic organs, but very often due to under-estimation of initial symptoms and thus inadequate treatment. For the proper diagnosis of traumatic lesions of the thorax the plain film of the chest is, therefore, fundamentally important. In this paper, which is mainly dealing with lesions of the airways and lungs, the significance of radiological symptoms is stressed and a correlation with pathophysiologic as well as histologic data is attempted.