case presentation ~ aortic disruption 2006/8/8 emergency/morning meeting ~presentation by 蕭卜源

Case Presentation ~Case Presentation ~ Aortic disruptionAortic disruption

2006/8/8Emergency/Morning meetingEmergency/Morning meeting

~Presentation by 蕭卜源

Patient profile 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 arrivalStatus on arrival• Traffic accident, referred from 建佑 Ho

spital• Vital sign ：

– BP 132/65mmHg – BT 36.9℃ – HR 96bpm– RR 10~24/min

• Consciousness: clear, E4V5M6

Primary ABCDEs and managemenPrimary ABCDEs and managementt• Airway:

– Collar– Speech

• Breathing: – Nasal cannula O2 2 L/min– Oximeter, SaO2 : 100%

• 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

ExposureExposure

abrasion

pain

Secondary ABCDEs and managemeSecondary ABCDEs and managementnt• Allergy: denied• Medicine: denied• Past illness:

– DM(-), HTN(-), Asthma(-), Pregnancy(-), other systemic disease: denied

• Last meal: unknown•

EventsEvents• Prehospital…

– Motorcycle V.S Trunk– Sent to 建佑 Hospital where (1)chest contu

sion R/O aortic dissection (2)rib fracture (3)abdominal contusion were impressed

– ILOC(+) ? min ( 不知如何被撞擊 ) – Child ?

AP and Lateral Views of C-AP and Lateral Views of C-SpineSpine

Right Forearm AP and Lateral Right Forearm AP and Lateral ViewsViews

AP View of the ChestAP View of the Chest

CT of Chest & AbdomenCT of Chest & Abdomen

Lab dataLab data• 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

Blood pressureBlood 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

CT of HeadCT of Head and C-spine and C-spine• Head

– No definite intracranial hemorrhage

• C-spine– The alignment of the C-spine is acceptable. – No fracture or dislocation is noted.

Tentative diagnosisTentative diagnosis• Aortic transection with hemomediastinum• Multiple left rib (7th to 10th) fractures with he

mothorax• Multiple lacerations of the liver with internal bl

eeding

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

Operation on 8/2Operation on 8/2• Pre-operation

diagnosis: traumatic aortic disruption (descending thoracic aorta)

• OP: excision of disruptive aortic isthmus with graft interposition + external corporeal circulation

Chest TraumaTraumatic Aortic Injury

~~trauma.org 9:4, April 2004

Blunt aortic injury Blunt aortic injury Presentation Injury Type Management

priorityDead Aortic transection/ ruptu

re Haemodynamically unstable

Haemorrhage from other sites/organsORAortic haemorrhage

Control haemorrhage

Haemodynamically stable

Contained aortic injury Blood pressure control

Algorithm for evaluation of blunt aortic injuryAlgorithm for evaluation of blunt aortic injury

Management Management • If the aorta is injured, but is not the source of active ha

emorrhage, it should be low on the list of management priorities, after haemorrhage control and neurologic stabilization.

Patients who can not or should not be operaPatients who can not or should not be operated on immediately include:ted 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 procedu

res • Patients with coagulopathy, hypothermia & acidosis• Patients with severe medical co-morbidities • Patients with burns or severe sepsis.

Controlling the blood pressure is important!!

Operative repair of aortic injury is indicateOperative repair of aortic injury is indicated for:d for:

• Haemodynamic instability • Large-volume haemorrhage from chest tubes • Contrast extravasation on CT or rapidly expanding me

diastinal haematoma • Penetrating aortic injury

Management of Blunt Thoracic Aortic Injury

European Journal of Vascular and Endovascular Surgery Volume 31, Issue 1 , January 2006, Pages 18-27

O. Nzewi, R.D. Slight and V. Zamvar

Introduction Introduction • blunt traumatic aortic transection (TAT) is an u

ncommon injury • the isthmus

– over 85% of cases arriving at hospital alive• transverse tears

Parmley Parmley et al.et al. classified the lesions in classified the lesions into six groups:to 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 lesion limited to the intima and media where the rupture is contained by the st

rength of the tunica adventitia and the mediastinal pleura

Algorithm for Screening Cases of Algorithm for Screening Cases of Suspected TATSuspected TAT

Immediate or Delayed Surgical RepairImmediate or Delayed Surgical Repair • 275 →38 →23• Emergency thoracotomy and repair should be r

eserved 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

Thanks for your attention~~