Written by Gabby Leonard
The Western Trauma Association Algorithms Committee has released new evaluation and management guidelines and a step-by-step algorithm (see below) surrounding blunt thoracic aortic injury.
Why does this matter?
Blunt thoracic aortic injury (BTAI) most often occurs distal to the takeoff of the left subclavian artery and is associated with high risk for mortality. Recent updates based on prospective and retrospective cohort studies guide decision making and intervention in these injuries.
Blunt thoracic aortic injury – no longer a mystery
Screening: Consider BTAI in high-energy mechanisms such as MVC or fall from height. CXR may show wide mediastinum, hemothorax, blunting of aortic knob, but beware of false negative screening CXR.
Diagnosis: CTA of chest (sensitivity 95-100%, NPV 99-100%) is best for ED evaluation. You may also consider transesophageal echocardiogram, intravascular ultrasound, or aortography – though this depends on your local resources.
Management: Use anti-impulse control with esmolol targeting a HR <100 and SBP <100. Consider diltiazem or vasodilator if no contraindication (i.e. TBI requiring cerebral perfusion). Avoid pure vasodilators (i.e. nitroprusside) as first-line agents. Medical management is meant to decrease risk of progression or free-rupture of the injury.
Grading: Grades I (intimal tear) and II (intramural hematoma) are low-grade injuries that may be managed with anti-impulse therapy and repeat CTA 2-3 days after admission. Grade III (pseudoaneurym) and Grade IV (rupture) are high-grade injuries that typically require surgical intervention after initial anti-impulse control.
Endovascular vs. Open Repair: TEVAR (thoracic endovascular aortic repair) is treatment of choice for BTAI to reduce mortality and paraplegia when compared to left posterolateral thoracotomy.
Post-repair Management: ICU admission is needed after TEVAR for monitoring. Goal is normal BP and heart rate. Consider surveillance of endograft with serial chest CTs.
Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2023 Jan 1;94(1):113-116. doi: 10.1097/TA.0000000000003759. Epub 2022 Aug 24.