Chest Injuries—Traumatic Aortic Injury

Traumatic aortic injury must be ruled out in any patient who has suffered a high-energy injury such as a motor vehicle accident or fall from a height. Aortic injury occurs most commonly just distal to the left subclavian artery and is the result of shear forces between the mobile heart and aortic arch and the immobile descending thoracic aorta. Traumatic aortic injury encompasses a continuum of injury from a small intimal flap to free transection contained by the surrounding mediastinum and pleura. The diagnosis is made by screening chest radiography, followed by definitive angiography, CT, or TEE. Surgical repair is indicated for most patients with traumatic aortic injury because of the high risk for rupture in the hours and days after injury. ^[202] Various techniques have been described for this highly morbid surgery, with the best reports recently attributed to partial bypass techniques using inflow from the left atrium, a centrifugal pump, and outflow to the descending aorta.^[203] Reports of selective nonoperative management of high-risk patients with traumatic aortic injury have appeared in the recent literature.^{[204] [205]} Treatment is similar to that of patients with uncomplicated type B aortic dissections and consists of β-blockade to minimize the cardiac rate-pressure product. No randomized trials have been conducted and the published case series are small, but it appears that with strict control of MAP and heart rate, long-term survival can be achieved.