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Background

Blunt Aortic Injury with Concomitant Intra-abdominal Solid Organ Injury: Treatment Priorities Revisited. Santaniello J, et al, The Journal of TRAUMA Injury, Infection, and Critical Care. 2002;53:442–445. Background. Blunt aortic injury (BAI): 90% mortality within first 24 hours

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Background

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  1. Blunt Aortic Injury with Concomitant Intra-abdominal Solid Organ Injury: Treatment Priorities Revisited Santaniello J, et al, The Journal of TRAUMAInjury, Infection, and Critical Care. 2002;53:442–445.

  2. Background • Blunt aortic injury (BAI): • 90% mortality within first 24 hours • Second leading cause of death in blunt trauma • 15%~20% BAI patient with concomitant liver/spleen (L/S) injuries • Cardiopulmonary bypass with heparinization for repair of BAI  L/S operation before aortic repair? • Majority of blunt L/S injuries are now treated non-operatively in hemodynamically stable patients • Evaluates safety of acute BAI repair using partial bypass with full heparinization in patients undergoing non-operative management (NOM) for low-grade blunt L/S injuries

  3. Patients and Methods • BAI patient in Presley Regional Trauma Center over a 6-year period • Study group: Patient with concomitant liver or spleen injury (Aorta L/S group) • Control: patient with L/S injury but without BAI (L/S group)

  4. Aortic Injury Management • Patient screened by chest & abdominal CT  thoracic aortography • Blood pressure and heart rate controlled pharmacologically to (SBP~100mmHg, HR < 100 bpm) • BAI repaired by partial bypass with full heparinization

  5. Solid Organ Injury Management • Diagnosed by CT and graded by American Assoiciation for the Surgery of Trauma organ injury scale • Aorta L/S vs. L/S • Aorta L/S vs. Aorta

  6. Results • 84 patients with BAI • 56 p’t without associated intra-abdominal injury • 28 p’t with concomitant liver and/or spleen injury • Aorta L/S group: 20 patients with solid organ injury (Table 1) • L/S group: 894 patients with grade I/II hepatic or splenic injury • Aorta L/S group vs. L/S group (Table 2) • Aorta L/S group vs. Aorta group (Table 3) • Complication rates (Table 4)

  7. Results • No difference in resource use (length of stay) or failure of non-operative solid organ injury management • Similar overall complication rate

  8. Discussion1 • Past: positive peritoneal lavage  laparotomy  aortic repair • Present: recent shift in management of blunt L/S injuries to non-operative management • Aortic repair with involvement of systemic anticoagulation  increase risk of hemorrhage? • Approaches to BAI with blunt L/S injury: 1. Delay repair of aorta until injured intra-abdominal organ has healed  longer hospital stay in increased costs 2. Perform laparotomy with removal or repair of injured solid organ with subsequent repair of aorta  high morbidity and risk of post-splenectomy sepsis syndrome 3. Clamp-and-sew method for aortic repair  cross-clamp time

  9. Discussion2 • No increase in the rate of NOM failure for solid organ injury when partial bypass with full heparinization were used • Low-grade liver and spleen injury can be anticoagulated acutely with little or no risk of delayed hemorrhage • Conclusion: An aortic injury in association with low-gradeliver or spleen injuries can be repaired acutely using partial bypass with full heparinization safely and effectively Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass

  10. Study Limitations • Retrospective, deals with grade I or II solid organ injury only • The safety of heparinizing patients with higher grades of liver or spleen injuries (III–V) was not studied, and no conclusions can be drawn for those patients • The high incidence of concomitant injuries, specifically, head injury and fractures, was not addressed

  11. Thanks for Your Attention!!!

  12. Aorta L/S Group

  13. Aorta L/S vs. L/S

  14. Aorta L/S vs. Aorta

  15. Complications • Similar overall complication rates (45% vs. 32%, p = NS)

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