Ministry of Health

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 Published: 28/11/2011

Aortic Rupture following Trauma

All trauma patients with an "appropriate mechanism of injury" (total body acceleration/deceleration e.g. road crashes [incl. pedestrians and cyclists] and falls >1 storey) are at risk for thoracic great vessel injury. Concerns must be discussed with consultants.

Suspicious clinical signs include:

    · neck haematoma
    · unilateral diminution or loss of pulse, asymmetric BP
    · radiofemoral delay (pseudocoarctation)
    · severe searing transthoracic pain

AP chest x-ray signs include:

    · Widened mediastinum >8cm
    · Loss of normal aortic contour
    · Opacification of aorta-pulmonary window
    · Apical capping
    · Displacement of mainstem bronchi (left down, right up), NG tube to the right
    · Fracture of first rib, scapula

The widened mediastinum requires further investigation. If possible an erect CXR should be obtained. If not, the trauma team leader should discuss with the interventional radiologist on call. The radiologist may read the CXR as 'normal', or may recommend other tests (arch aortogram, or multi-slice CT).
A widened mediastinum does not necessarily mean an abnormal mediastinum and an abnormal mediastinum may not necessarily be widened.

The investigations for great vessel injury are:

Arch Aortogram
    Indications:
        a. Appropriate mechanism and suspicious clinical signs
        b. Appropriate mechanism of injury and a CXR with abnormal mediastinum

Multi-slice CT Chest
    Can be helpful in resolving the diagnosis of abnormal mediastinum
    Requires the appropriate CT protocol (thoracic aorta dissection protocol)
    Can identify injuries that may otherwise be missed on plain films
    Is not useful for mediastinal haematoma if anatomical boundaries are obliterated by undrained
    haemothorax etc.

The decision to utilise aortogram or multi-slice CT chest is a consultant radiologist decision based on discussion with the trauma team leader. Consultant radiologist interpretation of suspicious CXR, CT and angiography is to be documented in the patient's chart on completion of the test.

In general, the investigation and the treatment of aortic rupture should follow treatment of expanding intracranial haemorrhage or active chest, abdominal, or pelvic bleeding.

Last updated on 28/11/2011