In blunt trauma patients with multiple injuries that include thoracic aortic injury, how is surgery prioritized?

In blunt trauma patients with multiple injuries that include thoracic aortic injury, how is surgery prioritized?

A patient with an injury that involves complete or a nearly complete circumferential transection of all three layers of the aortic wall is unlikely to arrive in the operating room. Those who make it to the surgery with this pathology generally have either a small perforation or a partial transection that is temporarily sealed with perivascular clot formation or a relatively large transection that bleeds at a relatively slow rate because of hypotension and possibly perivascular barriers such as adjacent tissues or clot covering the lesion. In our experience, patients who have up to 70% transection of the aortic circumference can survive until surgery. Most patients who arrive in the operating room have relatively small sealed subadventitial posterior wall injuries, which require surgical repair because of impending rupture. In addition, there are a significant number of patients who have intimal and/or medial layer injury, which can be managed conservatively or surgically, if necessary, on an elective basis. Undoubtedly, tho-racic aortic injury represents a true surgical emergency but not all types of traumatic lesions carry the same degree of urgency. Thus, in hemodynamically stable patients with no intracranial pathology, assessment of the type of vascular injury with contrast-enhanced spiral CT provides important information for surgical prioritization.

Another important factor is the type and extent of associ-ated injuries. Traumatic intracranial lesions and gross bleed-ing into body cavities are more emergent than stable aortic injuries seen on CT scan. In most instances, hypotension in these patients is caused by the associated injuries rather than the aortic injury itself, and at times these patients may have to be rushed to the operating room without any radiologic investigation. As mentioned, TEE in those circumstances helps immensely to determine the extent of aortic injury intraoperatively while the other injuries are being managed.

In summary, actively bleeding aortic injuries with hemodynamic instability have the highest surgical priority. If they occur concomitantly with unstable abdominal injuries or head injury, which is a relatively rare event, simultaneous intervention should be considered. In the absence of an unstable associated injury, the aortic injury should be repaired as early as possible.

Surgical repair of the thoracic aorta requires clamping of the vessel. In the presence of intracranial pathology this maneuver may result in an uncontrollable rise in intracranial pressure. Thus, a significant intracranial hematoma must be evacuated with at least a burr hole. For small intracranial traumatic lesions, monitoring of the intracranial pressure during the aortic repair may suffice.