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Case Presentation ~ Aortic disruption

Case Presentation ~ Aortic disruption. 2006/8/8 Emergency/Morning meeting ~Presentation by 蕭卜源. Patient profile. Name: 黃 X 雲 Age: 27 years old Gender: female Weight: 65 kg Height: 160 cm Chart number: 22988212 Admission date: 2006/07/27. Status on arrival.

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Case Presentation ~ Aortic disruption

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  1. Case Presentation ~ Aortic disruption 2006/8/8 Emergency/Morning meeting ~Presentation by 蕭卜源

  2. Patient profile • Name: 黃X雲 • Age: 27years old • Gender: female • Weight: 65 kg • Height: 160 cm • Chart number: 22988212 • Admission date: 2006/07/27

  3. Status on arrival • Traffic accident, referred from 建佑 Hospital • Vital sign： • BP 132/65mmHg • BT 36.9℃ • HR 96bpm • RR 10~24/min • Consciousness: clear, E4V5M6

  4. Primary ABCDEs and management • Airway: • Collar • Speech • Breathing: • Nasal cannula O2 2 L/min • Oximeter, SaO2 : 100%

  5. Circulation: • EKG monitor • HR: 96/min ; BP: 132/65mmHg • N/S 500ml ivd • FAST → • Disability: • GCS score: 15 • Light reflex of pupils: 3mm ; 3mm liver contusion, internal bleeding

  6. Exposure abrasion pain

  7. Secondary ABCDEs and management • Allergy: denied • Medicine: denied • Past illness: • DM(-), HTN(-), Asthma(-), Pregnancy(-), other systemic disease: denied • Last meal: unknown

  8. Events • Prehospital… • Motorcycle V.S Trunk • Sent to 建佑 Hospital where (1)chest contusion R/O aortic dissection (2)rib fracture (3)abdominal contusion were impressed • ILOC(+) ? min (不知如何被撞擊) • Child ?

  9. AP and Lateral Views of C-Spine

  10. Right Forearm AP and Lateral Views

  11. AP View of the Chest

  12. CT of Chest & Abdomen

  13. Amylase = 240 U/L Lipase = 186 IU/L PT p/c = 11.8/11.2 second PT(INR) = 1.08 R PTT p/c = 25.8/28.8 second WBC = 12.77 x1000/ul RBC = 3.56 x106/ul Hgb = 10.2 g/dl Hct = 33.2 % MCV = 93.3 fl MCH = 28.7 Pg MCHC = 30.7 g/dl PLT = 249 x1000/ul RDW-CV = 13.5 % RDW-SD = 46.4 fl Sugar = - g/dl protein: sulfo 2+ BIL = - KET = - SG = 1.031 OB = 3+ PH = 6.5 NIT = - WBC = - Color = Yellow Appearance = Clear RBC = 50-99 /HPF WBC = 0-2 /HPF Crystal = - /LPF Cast = - /LPF Lab data

  14. Blood pressure • 15:30 • RA 117/66 ; LA 92/61 ; RL 97/76 ; LL 126/46 • 18:05 • RA 110/62 ; LA 99/56 ; RL 113/65 ; LL 116/62 • 19:30 • RA 77/42 ; LA 113/74 ; RL 121/66 ; LL 122/68

  15. CT of Head and C-spine • Head • No definite intracranial hemorrhage • C-spine • The alignment of the C-spine is acceptable. • No fracture or dislocation is noted.

  16. Tentative diagnosis • Aortic transection with hemomediastinum • Multiple left rib (7th to 10th) fractures with hemothorax • Multiple lacerations of the liver with internal bleeding

  17. Plan • N/S 1000ml • NPO • PRBC 2u+12u transfusion • FFP 2u transfusion • Platelets 24u transfusion • Albumin 3 Bot • Cefazoline

  18. Operation on 8/2 • Pre-operation diagnosis: traumatic aortic disruption (descending thoracic aorta) • OP: excision of disruptive aortic isthmus with graft interposition + external corporeal circulation

  19. Chest TraumaTraumatic Aortic Injury ~~trauma.org 9:4, April 2004

  20. Blunt aortic injury

  21. Algorithm for evaluation of blunt aortic injury

  22. Management • If the aorta is injured, but is not the source of active haemorrhage, it should be low on the list of management priorities, after haemorrhage control and neurologic stabilization.

  23. Patients who can not or should not be operated on immediately include: • Patients who need to be transferred to other facilities for definitive repair • Severe head injury • Severe pulmonary injury • Haemodynamically unstable patients • Patients who have undergone damage control procedures • Patients with coagulopathy, hypothermia & acidosis • Patients with severe medical co-morbidities • Patients with burns or severe sepsis. Controlling the blood pressure is important!!

  24. Operative repair of aortic injury is indicated for: • Haemodynamic instability • Large-volume haemorrhage from chest tubes • Contrast extravasation on CT or rapidly expanding mediastinal haematoma • Penetrating aortic injury

  25. Management of Blunt Thoracic Aortic Injury European Journal of Vascular and Endovascular SurgeryVolume 31, Issue 1 , January 2006, Pages 18-27 O. Nzewi, R.D. Slight and V. Zamvar

  26. Introduction • blunt traumatic aortic transection (TAT) is an uncommon injury • the isthmus • over 85% of cases arriving at hospital alive • transverse tears

  27. Parmley et al. classified the lesions into six groups: • (1) intimal haemorrhage • (2) intimal haemorrhage with laceration • (3) medial laceration • (4) complete laceration of the aorta • (5) false aneurysm formation • (6) peri-aortic haemorrhage have sustained an incomplete non-circumferential lesionlimited to the intima and media where the rupture is contained by the strength of the tunica adventitia and the mediastinal pleura

  28. Algorithm for Screening Cases of Suspected TAT

  29. Immediate or Delayed Surgical Repair • 275 →38 →23 • Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. • operative mortality rate: 30% • age and pre-existing cardiac disease • operation immediately or delay longer than 24 h no difference

  30. Thanks for your attention~~

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