Aortic transection, diaphragmatic rupture and haemoperitoneum in a complex multitrauma patient

Case contributed by Dr Dayu Gai

Presentation

This 35 year old male had a high speed motorbike accident.

Patient Data

Age: 35 years
Gender: Male
  1. Blunt traumatic thoracic aortic transection and pseudoaneurysm with an associated large volume mediastinal haematoma.
  2. Left diaphragmatic rupture with stomach herniation into the chest. Left hemothorax and pulmonary contusions.
  3. Haemoperitoneum associated with blunt duodenal/jejunal injury, possible mesenteric tear, and a small subcapsular splenic contusion.
  4. Possible small blunt renal contusion.
  5. Right posterior 12th rib fracture.

Case Discussion

Traumatic aortic transection (TAT) is a condition which carries a mortality of over 90%1. The mechanism for this condition is movement of the aortic arch against the fixed proximal descending aortic segment. Given that TAT has such a high mortality rate associated with it, operative management is vital in those patients who survive. The mainstay of treatment who been with open surgical repair, involving thoracotomy and aortic crossclamping. More recently, however, thoractic endovascular aortic repair has been a less invasive alternative.

Diaphragmatic rupture is commonly found in blunt trauma (motor vehicle accidents and falls from height). The left sided diaphragm is usually involved. This has been speculated because of an intrinsically weaker left sided diaphragm, or because the liver on the right side provides protection2. Diaphragmatic rupture is clinically relevant because it may result in herniation and strangulation of intra-abdominal viscera into the thoracic cavity3.

Symptoms of diaphragmatic rupture include:

  • epigastric or chest pain
  • referred shoulder tip pain
  • respiratory distress due to compressed left lung

Once diagnosed, assessment and repair can be either with:

  1. Open repair with laparotomy
  2. Minimally invasive methods of repair including laparoscopy and thoracoscopy

Case contributed by A/Prof. Pramit Phal.

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Case Information

rID: 31701
Case created: 22nd Oct 2014
Last edited: 19th May 2016
Inclusion in quiz mode: Included

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