|
|
| Line 3: |
Line 3: |
| {{CMG}} | | {{CMG}} |
|
| |
|
| {{SK}} traumatic aortic disruption; transection | | {{SK}} Traumatic aortic disruption; transection |
|
| |
|
| ==Overview== | | ==[[ Traumatic aortic rupture overview|Overview]]== |
| Traumatic aortic rupture is a condition in which the [[aorta]], the largest [[artery]] in the body, is torn or ruptured as the result of trauma. | |
|
| |
|
| ==Pathophysiology== | | ==[[ Traumatic aortic rupture historical perspective|Historical Perspective]]== |
| ===Sheer Mechanism===
| |
| The injury is usually caused by high speed impacts such as those that occur in vehicle collisions and serious falls.<ref name="schrader"/> The location of the initial aortic tear is usually at the point in the proximal descending aorta with the greatest sheer where the relatively free and mobile [[aortic arch]] joins to the fixed [[descending aorta]] ([[ligamentum arteriousm]]). By far the most common site for tearing in traumatic aortic rupture is the [[aortic isthmus]], near where the left [[subclavian artery]] branches off from the aorta.<ref>{{cite journal | author = Phillips BJ | title = Traumatic Rupture Of The Thoracic Aorta: An Endoluminal Approach | journal = The Internet Journal of Thoracic and Cardiovascular Surgery | year = 2001 | volume = 4| number = 1 | issn = 1524-0274 | url = http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijtcvs/vol4n1/tar.xml}}</ref><ref>{{cite journal |author=McKnight JT, Meyer JA, Neville JF |title=Nonpenetrating Traumatic Rupture of the Thoracic Aorta |journal=Ann. Surg. |volume=160 |issue= |pages=1069-72 |year=1964 |pmid=14246145 |url=http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1408872&pageindex=1}}</ref> This junction of the free and fixed part of the aorta is at the greatest risk of transection as a result of the shearing forces due to sudden deceleration <ref>{{cite journal |author=Rittenhouse EA, Dillard DH, Winterscheid LC, Merendino KA |title=Traumatic rupture of the thoracic aorta: a review of the literature and a report of five cases with attention to special problems in early surgical management |journal=Ann. Surg. |volume=170 |issue=1 |pages=87-100 |year=1969 |pmid=5789533 |url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1387606&blobtype=pdf}}</ref> . Frontal or side impacts in [[motor vehicle accidents]] and falls from substantial heights pose the greatest risk of sheer.
| |
|
| |
|
| The aorta may also be torn at the point where it is connected to the heart. The aorta may be completely torn apart from the heart, but patients with such injuries very rarely survive for very long after the injury; thus it is much more common for hospital staff to treat patients with partially torn aortas.<ref name="schrader"/> When the aorta is partially torn, it may form a "pseudoaneurysm". In patients who do live long enough to be seen in a hospital, a majority have only a partially torn blood vessel, with the layer called the [[adventitia]] still intact.<ref name="Rousseau"/> In some of these patients, the adventitia and nearby structures within the chest may serve to prevent [[severe hemorrhage]].<ref name="Rousseau"/>
| | ==[[ Traumatic aortic rupture pathophysiology|Pathophysiology]]== |
|
| |
|
| ===Compressive Mechanism=== | | ==[[ Traumatic aortic rupture causes|Causes]]== |
| Extrinsic compression of teh aorta between the sternum and the spine may contribute at least in part to aortic rupture.
| |
|
| |
|
| ===Elevated Intra-aortic Pressure Mechanism=== | | ==[[ Traumatic aortic rupture differential diagnosis|Differentiating Traumatic aortic rupture from other Diseases]]== |
| A sudden, dramatic rise in intra-luminal aortic pressure at the time of impact may contribute to aortic rupture.
| |
|
| |
|
| ==Causes== | | ==[[ Traumatic aortic rupture epidemiology and demographics|Epidemiology and Demographics]]== |
| *Blunt [[chest trauma]]
| |
| *[[Falling]] from a height
| |
| *[[Motor vehicle accidents]]
| |
|
| |
|
| ==Natural History, Complications, Prognosis== | | ==[[ Traumatic aortic rupture risk factors|Risk Factors]]== |
| The condition is frequently fatal due to the [[massive bleeding]] that results from the rupture. Since the aorta branches directly from the [[heart]] to supply [[blood]] to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in [[hemorrhagic shock]] and death.
| |
|
| |
|
| Death occurs immediately after traumatic rupture of the thoracic aorta 75% to 90% of the time since bleeding is so severe, and 80 to 85% of patients die before arriving at a hospital.<ref name="Rousseau"/> Though there is a concern that a small, stable tear in the aorta could enlarge and cause complete rupture of the aorta and heavy bleeding, this may be less common than previously believed as long as the patient's blood pressure does not get too high.<ref name="Rousseau"/>
| | ==[[ Traumatic aortic rupture natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| | |
| Patients who survive to hospital admission generally have a partial tear with pseudoaneurysm formation.
| |
| | |
| ==Epidemiology and Demographics== | |
| Traumatic aortic rupture is a common killer of victims of [[car accident|automotive accidents]] and other traumas,<ref name="schrader">{{cite web | author = Schrader L, Carey MJ | title = Traumatic Aortic Rupture | work = The Doctor Will See You Now | url = http://www.thedoctorwillseeyounow.com/articles/heart/tar_6/ | year = 2000 | publisher = interMDnet Corp. | accessdate = 2007-07-21}}</ref> with up to 18% of deaths that occur in automobile collisions being related to the injury.<ref name="Rousseau">{{cite journal |author=Rousseau H, Soula P, Perreault P, ''et al'' |title=Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent |journal=Circulation |volume=99 |issue=4 |pages=498-504 |year=1999 |pmid=9927395 |url=http://circ.ahajournals.org/cgi/content/full/99/4/498}}</ref> In fact, aortic disruption due to blunt [[chest trauma]] is the second leading cause of injury death (behind [[traumatic brain injury]]).<ref name="Plummer">{{cite journal |author=Plummer D, Petro K, Akbari C, O'Donnell S |title=Endovascular repair of traumatic thoracic aortic disruption |journal=Perspectives in vascular surgery and endovascular therapy |volume=18 |issue=2 |pages=132-9 |year=2006 |pmid=17060230 |doi=10.1177/1531003506293453}}</ref> | |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[ Traumatic aortic rupture history and symptoms|History and Symptoms]] | [[ Traumatic aortic rupture physical examination|Physical Examination]] | [[ Traumatic aortic rupture laboratory findings|Laboratory Findings]] | [[ Traumatic aortic rupture electrocardiogram|Electrocardiogram]] | [[ Traumatic aortic rupture chest x ray|Chest X Ray]] | [[ Traumatic aortic rupture CT|CT]] | [[ Traumatic aortic rupture MRI|MRI]] | [[ Traumatic aortic rupture echocardiography|Echocardiography]] | [[ Traumatic aortic rupture other imaging findings|Other Imaging Findings]] | [[ Traumatic aortic rupture other diagnostic studies|Other Diagnostic Studies]] |
| The condition is difficult to detect and may go unnoticed. Most patients have no symptoms. However, a minority of patients may have some of the following symptoms<ref name="schrader"/>:
| |
| *[[Hoarse]]
| |
| *[[Dyspnea]] or [[find it difficult to breathe or speak]]
| |
| *[[Shortness of breath]]
| |
| *[[Chest pain]]
| |
| *[[Upper back pain]]
| |
| | |
| The diagnosis is further complicated by the fact that many patients with the injury experienced multiple other serious injuries as well,<ref>{{cite journal |author=Vloeberghs M, Duinslaeger M, Van den Brande P, Cham B, Welch W |title=Posttraumatic rupture of the thoracic aorta |journal=Acta Chir. Belg. |volume=88 |issue=1 |pages=33-8 |year=1988 |pmid=3376665 |doi=}}</ref> so the attention of hospital staff may be distracted from the possibility of aortic rupture.
| |
| | |
| ===CT===
| |
| The preferred method of diagnosis is [[aortography]].
| |
| | |
| ===Chest X Ray===
| |
| Though not completely reliable, chest [[X-ray]]s are sometime used to diagnose the condition. Signs include aortic dilation and [[hemothorax]].
| |
| | |
| ===Chest Tube Drainage===
| |
| If a [[chest tube]] drains a large amount of bright red arterial blood, or if there is sustained drainage of over 200mls, then aortic rupture should be suspected and the patient should undergo thoracotomy.
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
| Traumatic aortic rupture is treated with surgery. However, [[morbidity]] and [[mortality rate]]s for surgical repair of the aorta for this condition are among the highest of any cardiovascular surgery.<ref name="Plummer"/> For example, surgery is associated with a high rate of [[paraplegia]],<ref>{{cite journal |author=Attar S, Cardarelli MG, Downing SW, ''et al'' |title=Traumatic aortic rupture: recent outcome with regard to neurologic deficit |journal=Ann. Thorac. Surg. |volume=67 |issue=4 |pages=959-64; discussion 964-5 |year=1999 |pmid=10320235 |doi=}}</ref> because the [[spinal cord]] is very sensitive to [[ischemia]] (lack of blood supply), and the nerve tissue can be damaged or killed by the interruption of the blood supply during surgery. | | [[ Traumatic aortic rupture medical therapy|Medical Therapy]] | [[ Traumatic aortic rupture surgery|Surgery]] | [[ Traumatic aortic rupture primary prevention|Primary Prevention]] | [[ Traumatic aortic rupture secondary prevention|Secondary Prevention]] | [[ Traumatic aortic rupture cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[ Traumatic aortic rupture future or investigational therapies|Future or Investigational Therapies]] |
| | |
| Since a high [[blood pressure]] could exacerbate the tear in the aorta or even separate it completely from the heart, which would almost inevitably kill the patient, hospital staff take measures to keep a patient's blood pressure low.<ref name="schrader"/> Such measures include giving [[pain medication]], administration of [[beta blockers]], keeping the patient calm, and avoiding procedures that could cause [[gagging]] or [[vomiting]].<ref name="schrader"/>
| |
| | |
| ==See also==
| |
| *[[Chest trauma]]
| |
| *[[Aortic dissection]]
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
|
| | == Case Studies == |
| | [[ Traumatic aortic rupture case study one|Case #1]] |
| ==External links== | | ==External links== |
| *[http://www.trauma.org/archive/thoracic/CHESTaorta.html Chest Trauma: Traumatic Aortic Injury] from Trauma.org | | *[http://www.trauma.org/archive/thoracic/CHESTaorta.html Chest Trauma: Traumatic Aortic Injury] from Trauma.org |