Aortic transection, diaphragmatic rupture and hemoperitoneum in a complex multitrauma patient
Presentation
Involved in a high speed motorbike accident.
Patient Data
- Blunt traumatic thoracic aortic transection and pseudoaneurysm with an associated large volume mediastinal hematoma.
- Left diaphragmatic rupture with stomach herniation into the chest. Left hemothorax and pulmonary contusions.
- Hemoperitoneum associated with blunt duodenal/jejunal injury, possible mesenteric tear, and a small subcapsular splenic contusion.
- Possible small blunt renal contusion.
- 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:
- Open repair with laparotomy
- Minimally invasive methods of repair including laparoscopy and thoracoscopy
Case contributed by A/Prof. Pramit Phal.