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