Penetrating Aortic Injury: A Single Center Experience
Meredith Sommerville, MD, Peter Ekeh, MD, Priti Parikh, MD, John K. Bini, MD.
Miami Valley Hospital
Penetrating aortic trauma continues to be a problematic clinical entity with significant morbidity and mortality which has
improved little even with the implementation of a resuscitation protocol [1-10]. These patients generally present in profound shock
and the mortality associated with these injuries has remained similar to the first reports by DeBakey – approximately 50-70% [1-10].
It has been theorized that a shortened time from resuscitation to laparotomy may result in a decreased risk of mortality [10]. Despite
this, a majority of risk factors for increased mortality cannot be modified including shock and acidosis at presentation.
There is a considerable need for the study of diagnosis, resuscitation and treatment of penetrating aortic trauma. Through the
conduct of this investigation, it is our hope that an improved understanding of the optimal treatment of this entity will be achieved.
Experimental Design/Methods
Study Design: Retrospective study of the diagnosis, management and outcomes of penetrating thoracic and abdominal aortic
injury. Hospital medical records will be utilized to abstract prescribed data elements for analysis.
Data Collection and Statistical Analysis: Standardized data will be collected for each patient identified from the MVH
Trauma Registry including presenting vitals, laboratory results at presentation, emergency room management, and final outcomes
including mortality, renal failure, and paralysis entered into an excel spreadsheet. All patients treated at MVH with the diagnosis of
penetrating thoracic aortic injury or penetrating abdominal aortic injury between 2006 and 2014. All patients treated at MVH with the
diagnosis of blunt thoracic or abdominal aortic injury were excluded from the analysis. Due to the poor accrual of patient data, the
results were analyzed in a descriptive manner.
Results
Twelve patients were identified with penetrating thoracic or abdominal aortic injuries between the dates of 2005 and 2015.
Mean age at presentation was 38 with a range from 19-72. Ten patients were male and two were female. Five of twelve patients
succumbed to the injuries sustained resulting in a mortality rate of 42%. Ten patients required ventilator support for an average of 5
days; the two patients who did not succumbed to hemodynamic instability due to blood loss in the emergency department. Four
patients underwent emergency thoracotomy with a 50% mortality rate associated with the procedure. Seven patients required
transfusion with an average requirement of 16 units of packed red blood cells. A subset of 3 patients underwent massive transfusion
with an average of 33 units of packed red blood cells, 22 units of fresh frozen plasma, and 10 packs of platelets. Two of these three
patients survived to discharge.
Meredith E. Sommerville, MD
128 E. Apple Street
Dayton, OH 45409
Ph: 7702961702
Fax: 9372082105
Vitals upon presentation were available on only eight of the patients with three presenting with hypotension and with four
patients documented with unobtainable blood pressures. Only one patient presented normotensive without tachycardia. Laboratory
values upon presentation were even more difficult to obtain with white blood cell counts in 9 patients, INR in 6 patients, base deficit
in 7 patients and lactate in only 2 patients.
No patients developed chronic renal failure with a dependence upon hemodialysis but one patient did require temporary
hemodialysis due to an acute kidney injury associated with ischemic acute tubular necrosis during operative repair. This same patient
developed paraplegia as well. One patient developed a ventilator associated pneumonia and one patient developed a urinary tract
infection. No patients were diagnosed with acute respiratory distress syndrome.
Discussion
This is a single center description of experience over 2006-2014. Despite being a major level 1 trauma center for the area,
few penetrating injuries to the aorta were identified under-powering the study to assess differences in characteristics upon presentation
which may affect mortality. An extensive review of the literature finds a significant gap in understanding the signs upon presentation
which would aid in resuscitative measures for patients who have sustained these injuries. It is well known that patients who present
with hypotension which is not relieved by either judicious resuscitation or thoracotomy have poor prognoses. However, there is a
suggestion that maintaining the transfusion requirement to less than 10 units of product has a protective benefit.[13, 18, 20]
Additionally, the merit of an emergency thoracotomy has been drawn into question. Some reports indicate that very few
patients survive the procedure. However, as the indications for performance include a patient in extremis it would suggest that any
survival rate is a reason to continue the procedure. [15, 17, 20]
These are preliminary results of a single institution with plans to widen our patient inclusion through the national trauma
databank. This will provide a larger patient population to assess the mortality associated with the injury, merit of emergency
thoracotomy for resuscitation, incidence of associated complications such as renal failure, ventilator dependence, and paralysis, as
well as transfusion requirements.
Meredith E. Sommerville, MD
128 E. Apple Street
Dayton, OH 45409
Ph: 7702961702
Fax: 9372082105
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Meredith E. Sommerville, MD
128 E. Apple Street
Dayton, OH 45409
Ph: 7702961702
Fax: 9372082105