Original Articles
Clinical and radiographic indications for aortography in blunt chest trauma

https://doi.org/10.1067/mva.1987.avs0060168Get rights and content

Abstract

To determine which clinical and radiographic findings are valuable in selecting patients with blunt chest trauma for aortography, we analyzed the medical records and admission chest radiographs of 76 consecutive victims of blunt chest trauma with suspected thoracic aortic rupture during the past 7 years. All patients were evaluated by history, physical examination, chest radiography, and aortography; a total of 70 clinical and radiographic findings were independently assessed in each patient. The following occurred with significantly greater frequency in patients with thoracic aortic rupture than in those without: history of significant hypotension (mean arterial pressure less than 80 mm Hg) (p < 0.04); the presence of upper extremity hypertension, bilateral lower extremity pulse deficits, or an initial chest tube output greater than 750 ml of blood (p < 0.05); and greater incidence of myocardial contusions, intra-abdominal injuries, and pelvic fractures compared with patients without thoracic aortic rupture (p < 0.05). Mediastinal widening (equal to or greater than 8 cm) shown on anteroposterior chest radiography occurred in all patients with thoracic aortic rupture; however, its specificity was only 10.6%. Radiographic signs that were helpful in indicating the presence of thoracic aortic rupture included paratracheal stripe greater than 5 mm, rightward deviation of the nasogastric tube or central venous pressure line, blurring of the aortic knob, and an abnormal or absent paraspinous stripe. Upper rib fractures and mediastinal to thoracic cage width ratios at any level did not increase diagnostic accuracy for thoracic aortic rupture in the present series. Six patients in the series died, two of whom had thoracic aortic rupture. Complications from aortography occurred in eight patients (10.5%), one of whom required blood transfusion for severe groin hemorrhage. A branch-chain decision tree (clinical algorithm) was described as an approach to rapid diagnosis and treatment of patients with severe or high velocity deceleration blunt chest trauma. (J VASC SURG 1987;6:168-76.)

Section snippets

Patients

During the 7-year period from January 1978 to January 1985, 76 consecutive patients with suspected thoracic aortic rupture were evaluated by history, physical examination, chest radiography, and aortography. Patients suspected of having great vessel injuries other than the thoracic aorta were excluded from the study. Patients ages ranged from 14 to 76 years (37 ± 17 years [mean ± standard deviation]); 62 patients were male and 14 were female. The medical records of all 76 patients with

Clinical findings

Symptoms were unobtainable in 17 patients (22.4%) as a result of coma caused by closed head injury. Of the 59 patients in whom symptoms could be elicited, 37 (62.7%) complained of chest pain; only seven of these patients (11.9%) had thoracic aortic rupture (Table I). However, midscapular back pain was found in 12 conscious patients (20.3%), three of whom had thoracic aortic rupture. Of the nine patients with complaints of midscapular back pain without thoracic aortic rupture, eight had thoracic

Discussion

According to Sailer,28 the first case of thoracic aortic aneurysm thought to be due to trauma was reported in 1556 by Vesalius. In today's era of high-speed motor vehicles and complex freeway systems, and estimated 7500 motor vehicle accident victims die each year as a result of thoracic aortic rupture.29 The key to successful management lies in the principles of prompt diagnosis and surgical repair.2

Data of the present series indicate that a mediastinal width greater than 8 cm seen on standard

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    Reprint requests: William C. Shoemaker, M.D., Department of Surgery, Drew Postgraduate Medical School, 1621 East 120th St., Los Angeles, CA 90059.

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