HEART
May 1, 2000

Traumatic Aortic Rupture

Lynn Schrader, M.D., and Martin J. Carey, M.D.
Car crash victims who have difficulty speaking or swallowing may havea torn aorta, a life-threatening medical emergency.
Dr. Lynn Schrader is board certified in emergency medicine and is currently an Assistant Professor of Emergency Medicine at the University of Arkansas where her focus is on EMS disaster medicine and trauma care.


Suppose you are suddenly called to the hospital because your son or brother has been in a car accident. He survives and makes it to the local emergency room, awake and apparently in pretty good shape, but then turns out to have suffered a serious heart injury. His aorta, the main trunk through which the heart pumps blood into the arteries, is ruptured, or partially torn away from the heart. Called traumatic aortic disruption, this is a common cause of death in automobile collisions and other accidents. As serious and as common as it is, however, traumatic aortic disruption can be surprisingly difficult for doctors or emergency medical staff to detect.

The following scenario is designed to take you through a typical case and to tell you what you would want to know if you were to find yourself or a loved one in this all-too-common situation.

EMS Radio Report
"County emergency! This is EMS Unit 201 en route with a single patient from a two-car, head-on road crash," the EMS radio broadcasts.

The patient is a 21-year-old male, un-seatbelted passenger who was briefly trapped in the vehicle. The steering wheel was broken and the windshield smashed. Bystanders report that the patient was unconscious for a few minutes after the accident. However, he is now awake but confused and agitated.

"The patient has slightly elevated blood pressure, facial cuts and blood in both nostrils. Breathing okay, lungs are clear. No obvious damage to the abdomen," the EMTs radio.

The patient has been strapped to a board and put in a cervical collar to protect his spine from further injury, and has been given an oxygen mask and IV saline.

"We will be in the department in two minutes."

Arrival in the ER
On arrival in the emergency room, the patient complains loudly of neck, back, chest and knee pain. He remains agitated, giving the ER staff a hard time. His blood pressure is taken again and is now a bit higher. His neuro exam appears normal. No apparent neck or back injury. With his stethoscope, the doctor hears some crackling sounds around the left lung. The patient's chest is slightly bruised but the doctor hears no unusual sounds from the heart. Pulse is strong. The doctor orders x-rays of the neck, spine, chest and pelvis.

When the ER doctor looks at the chest x-ray, he is surprised to find signs of traumatic aortic disruption, a potentially fatal heart injury. Indeed, nearly 90% of patients with aortic injuries die before they even get to the ER. Among those who have this injury and arrive alive at the hospital, 20-30% will die in the first six hours, 40-50% in the first 24 hours and 60-80% in the first week.

Traumatic Aortic Disruption: What Is It?
Traumatic aortic disruption is caused by the shearing forces of high-speed front and side impact automobile accidents and by falls from great heights that tear the aorta away from the heart. The ER staff normally sees cases where the aorta is only partially disrupted because a complete disruption will kill a victim within moments of the accident, usually at the scene.

Unlike broken bones or bleeding wounds, partial aortic injury can be difficult to detect for a harried ER doctor. Further complicating matters is that many car accident victims have all sorts of other life-threatening injuries that demand immediate attention. A small minority of patients with traumatic aortic disruption may have chest or upper back pain that increase as blood pressure increases; this is a warning sign that the aorta is about to tear away completely from the heart. Even fewer complain of difficulty swallowing, difficulty speaking, hoarseness, or shortness of breath — all possible signs of a torn aorta. Frighteningly, most have no symptoms at all.

Traumatic aortic disruption often first shows up on a chest x-ray, although a chest x-ray does not always settle the matter. A normal chest x-ray does not completely rule out aortic injury and false-positive results are not uncommon. Part of the problem is that it can be difficult to move seriously injured patients into the best position to be x-rayed clearly. For this reason, doctors sometimes look for traumatic aortic disruption using other diagnostic techniques, such as transesophageal echocardiography (TEE), which can be done at the patient's bedside, or contrast-enhanced CT scan (computed tomography), also known as a CAT scan.

What's the Treatment?
Once traumatic aortic disruption is confirmed, the only treatment is surgery. The question is whether or not to operate immediately. The answer depends on what other injuries the patient has suffered and whether the aortic rupture is likely to get worse suddenly. Since the forces that cause aortic injury are tremendous, they often cause other injuries that are more immediately life threatening. In these cases, the ER doctor may decide to treat these injuries before doing heart surgery.

Whatever the decision, the doctor must continue to watch carefully for elevated blood pressure. Elevated blood pressure can sometimes cause a ruptured aorta to tear away completely, which would be fatal. Finally, any procedure that can make a patient gag and vomit, such as the use of a nasogastric tube to remove blood from the stomach, should be avoided as the straining from gagging and vomiting could further injure the torn aorta. Emphasis has to be placed on keeping the patient as comfortable and calm as possible. As part of this effort, the patient needs to be given enough pain-relief medicine to help keep their blood pressure down.

Conclusion
Though often hard to detect and, sometimes, virtually invisible, traumatic aortic disruption is one of the main causes of death after a car accident or similar severe injury. Survival is often a matter of getting to the ER right away — and finding an observant and alert medical staff.
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