Factors predicting early in-hospital death in blunt thoracic aortic injury

Despite technical advances in the diagnosis and repair of blunt thoracic aortic injury (TAI),1,2 patients continue to die after arrival at trauma centers. Most of these deaths occur consequent to free intrapleural aortic rupture before surgical repair. We sought to identify characteristics of the subpopulation of blunt TAI patients at particular risk for early in-hospital death.

The records of a Level I trauma center were reviewed for the period from 1/1/90 through 5/1/00. Fifty-one patients with aortic injury were identified. A subgroup was identified with isolated aortic injury. The resultant study group consisted of 26 patients and included 11 cases of free rupture (FR) and 15 cases of contained rupture (CR). Data from both groups were analyzed for mechanism, abnormal vital signs, initial chest radiographic findings, symptoms, physical findings, time course from injury to rupture or treatment, clinical outcome, and pathologic findings.

All 11 of the FR group died. In the CR group, 14/15 survived. Mechanism in all cases was "high-speed" or "head-on" motor vehicle collision. All cases with FR had the mediastinal abnormalities of "grossly widened mediastinum" + hemothorax; 10/11 had an episode of transient hypotension that initially responded to fluid resuscitation before their terminal event. In the CR group, there were a variety of chest radiographic findings, but only one "grossly widened mediastinum," no hemothorax, and no incidences of hypotension. However, multivariate analysis revealed that the combination of grossly widened mediastinum + hemothorax + transient hypotension was strongly and uniquely associated with those patients who went on to have free rupture (FR group) (p < 0.00001, Fisher's exact test).

For patients exposed to a high-speed decelerative mechanism, the constellation of "grossly widened mediastinum + hemothorax with transient hemodynamic instability" appears not only to be highly specific for aortic injury but also to be a marker of impending sudden death from free rupture. This association would seem to warrant immediate surgery in this high-risk group without the traditional diagnostic studies.