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Ann Thorac Surg 2007;83:1234-1235
© 2007 The Society of Thoracic Surgeons
Department of Surgery and the Trauma Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Suite H1-71, Toronto, Ontario, M4N 3M5 Canada
(Email: sandro.rizoli{at}sunnybrook.ca).
We previously reported on the emerging injury complex of blunt diaphragm rupture (BDR) and blunt aortic injury (BAI) [1]. After reviewing 10 additional years of experience and data, we found that this important association remains present today.
The results show that a total of 9,734 blunt trauma patients were treated at Sunnybrook Regional Trauma Unit from January 1986 to December 2003 (18 years). Of these, 176 patients were identified from the trauma registry as having suffered BDR at a rate of 1.8%. The rate of BAI overall in blunt trauma patients was 1.2% during the study period. Of the 176 patients with BDR, 13 patients also had an associated BAI at a rate of 7.4%. As such, patients with BDR had approximately a 6 times increased risk of suffering an associated BAI.
Review of these 13 cases revealed the following: mean age of 42 years, 31% were male, 77% were secondary to motor vehicle collisions (MVC), and mean injury severity score was 48. Their mean length of stay in the hospital was 38 days and mortality was 33%. All 13 patients had significant associated injuries (head in 6, pulmonary contusion in 10, hemopneumothorax in 10, intraabdominal injuries in 13, pelvic fracture in 9, and extremity injury in 12).
Diaphragmatic rupture occurs in 1% to 2% of blunt trauma patients, is generally due to MVCs, and usually involves a large tear on the left side [2]. This represents a diagnostic challenge, and as such clinicians must maintain a high index of suspicion. The diagnosis is usually made with a chest roentgenogram, or less commonly computed tomographic (CT) scan or diagnostic peritoneal lavage. This rupture is often only diagnosed at the time of laparotomy. Treatment is primary repair and associated injuries are important in determining outcomes.
Blunt aortic injury occurs in 7 of every 10,000 MVCs [3]. Only 10% to 20% of trauma patients with this injury will survive. It almost always involves a tear at the ligamentum arteriosum and historically was believed to be universally due to a deceleration force. Current thinking suggests a multifactorial cause, including the "osseous pinch" mechanism, "torsion stress," and "water-hammer stress" [3]. There are often associated severe injuries in the head, chest, and abdomen. Diagnosis is usually made with CT scan (or aortography). Treatment is either urgent or delayed repair.
Blunt diaphragm rupture associated with BAI is seen less frequently than either injury alone, and few reports have examined this association [1]. Similar to our previous report, we found a high association (7.4%) of BAI in patients with BDR. The lack of reported association in the literature may be due to missed diagnosis of BAI, or it may reflect a true change in injury pattern and severity over time.
When comparing our previous review with this update, the principal difference is our use of diagnostic imaging procedures for the thoracic aorta. Previously an aortogram was obtained at our center to rule out BAI only if the chest roentgenogram was abnormal. Since our findings in 1994, presently our practice is to obtain a mandatory CT angiogram of the chest (CTA) in every patient with BDR to undergo an active search for BAI, as well as in general, in any patient with evidence of head, chest, or abdominal trauma. The consequence is that today at Sunnybrook Trauma Unit, 53.64% of our blunt trauma patients (472 of 880 patients) in 2004 underwent CTA of the chest compared with 9.05% (55 of 608 patients) previously in 1996.
The BAI is unreliably assessed by chest roentgenogram, especially if there is a BDR. A CT scan of the thorax is increasingly used as a screening tool for BAI and has been proven to be reliable in that capacity [4]. With improved technology, such as the multi-slice helical high-resolution scans, the CT scan has now become the gold standard for definitive diagnosis in centers where this technology is available. In our center, if there are no direct signs of aortic injury, regardless of the presence of mediastinal hematoma, we do not routinely obtain an aortogram. Detailed anatomic information, such as the location and extent of pseudoaneurysm and tears, and vessel involvement from the two-dimensional and three-dimensional reconstructions of the CT scan are now used for operative planning.
The characteristics, associated injuries, treatment, and outcome of BAI associated with BDR remain the same. Our management of patients with BDR and BAI is as follows. If the patient is stable, then the aorta is preoperatively assessed with a CT. The diaphragm is usually repaired primarily. The aorta is operatively repaired immediately, or in a delayed fashion if severe head injury exists or pulmonary contusion precludes single-lung ventilation during the operation [5]. If the patient is unstable hemodynamically, imaging of the aorta is obtained using a CT scan after laparotomy. In the near future, it is anticipated that many blunt thoracic aortic injuries will be managed with endovascular techniques.
In summary, our findings 12 years ago remain valid today. The BAI occurs much more frequently in patients with BDR than the blunt trauma patient in general, and thus it mandates a rigorous search to rule it out. The major change in these patients has been in the diagnosis of BAIs, with CTA being done more frequently in our center.
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