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

2. 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

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, E 4 V 5 M 6

4. Primary ABCDEs and management Airway: –Collar –Speech Breathing: –Nasal cannula O 2 2 L/min –Oximeter, SaO 2 : 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

17. Lab 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 x10 6 /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

18. 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

19. 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.

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

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

22. 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

23. Chest Trauma Traumatic Aortic Injury ~~trauma.org 9:4, April 2004

24. Blunt aortic injury PresentationInjury TypeManagement priority DeadAortic transection/ rupture Haemodynamically unstable Haemorrhage from other sites/organs OR Aortic haemorrhage Control haemorrhage Haemodynamically stable Contained aortic injuryBlood pressure control

25. Algorithm for evaluation of blunt aortic injury

26. 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.

27. 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!!

28. 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

29. 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

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

31. 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 lesion limited to the intima and media where the rupture is contained by the strength of the tunica adventitia and the mediastinal pleura

32. Algorithm for Screening Cases of Suspected TAT

33. 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

34. Thanks for your attention~~