Talk:Thoracic aorta injury

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I added to the diagnosis section including signs to look for on a CT --JacksLog (talk) 21:30, 6 December 2019 (UTC) I just added the epidemiology section. --JacksLog (talk) 20:24, 6 December 2019 (UTC) Update on the article. I have just added the symptoms, mechanism, imaging aspect of diagnosis, treatment, and the outcome section. I am still working on each of the sections, but wanted to place my work into the article so if anyone notices any changes that need to be made they can add them. I have not changed anything that was already in the article. I have also realized it is difficult to add to the epidemiology portion that I planned on doing. So if anyone has any information specifically on epidemiology please add it in. Thanks everyone!--JacksLog (talk) 17:46, 27 November 2019 (UTC)

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 18 November 2019 and 14 December 2019. Further details are available on the course page. Student editor(s): JacksLog. Peer reviewers: Paj204.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 11:19, 17 January 2022 (UTC)

Symptoms

It is difficult to rely on symptoms to diagnose a thoracic aortic injury. However some symptoms do include severe chest pain, cough, shortness of breath, difficulty swallowing due to compression of the esophagus, back pain, and hoarseness due to involvement of the recurrent laryngeal nerve. There might be external signs such as bruising on the anterior chest wall do to a traumatic injury. Clinical signs are uncommon and nonspecific but can include generalized hypertension due to the injury involving the sympathetic afferent nerves in the aortic isthmus. A murmur can also be audible as turbulent blood flow goes over the tear.

Mechanism

The aortic wall is made up of three different components the intima (innermost layer), media (muscular layer), and adventitia (outermost layer). A traumatic injury to the thoracic aorta can cause disruption of any of these parts. Therefore aortic injury is on a scale from injury of a small intimal flap to free transection.

There are 4 grades of aortic injury.

• Type I: Intimal tear
• Type II: Intramural hematoma
• Type III: Pseudoaneurysm
• Type IV: Rupture

In addition to the 4 grades of aortic injury the risk of rupture can also be categorized. If the intima and the full thickness media are both involved in the injury then the injury is categorized as significant aortic injury. If the intima and just the inner layer of the media are involved in the injury then the injury is characterized as minimal aortic injury. Radiographically this would be seen as an intimal flap less than 1cm in size.

Between the mobile ascending aorta and the relatively fixed descending thoracic aorta is the aortic isthmus. When there is a sudden deceleration the mobile ascending aorta pushes forward creating a whiplash effect on the aortic isthmus. However, a different mechanism is involved when the ascending aorta proximal to the isthmus is torn. When there is a rapid deceleration the heart is pushed to the left posterior chest. This causes a sudden increase in intra-aortic pressure and can cause aortic rupture. This is known as the water hammer effect.

Based on the location of the injury in the thorax subsequent injuries can take place. If the injury is in the descending thoracic aorta this could lead to a hemothorax. Where as an injury to the ascending aorta could lead to hemoperricardium and subsequent tamponade or could compress the SVC.

Diagnosis

The gold standard for diagnosis of thoracic aortic injury is aortagraphy. The primary benefit of aortagraphy is the ability to precisely determine the location of injury for surgical planning. Another imaging modality is CT angiogram which has a sensitivity of 100%. Since a CT angiogram has a sensitivity of 100% and less invasive than aortagraphy it is the primary imaging choice. This allows visualization of the aorta and provides precise locations of traumatic injury. However, non contrasted CT scans, chest X-rays, and trans esophageal echo can also be used. Chest X-rays most sensitive finding is a widened mediastinum of greater than 8 cm. An apical cap and displacement of the trachea can also bee seen. A normal chest X-ray however does not exclude a diagnosis of thoracic aortic injury. A chest X-ray can also be useful to diagnose subsequent problems caused by aortic rupture such as pneumothorax or hemothorax. CT scans might show an intimal flap, periaortic hematoma, luminal filling defect, aortic contour abnormality, pseudoaneurysm, contained rupture, vessel wall disruption, active extravasation of intravenous contrast from the aorta and is therefore useful to assess for minimal aortic injury. Trans esophageal echos are useful in patients that are hemodynamically unstable, but the sensitivity and specificity of this study varies based on clinical user. If esophageal injury is expected or the patient has difficulty maintaining their away then the trans esophageal echo is contraindicated.

Treatment

The first line treatment for patients with thoracic aortic injury is maintaining the patient's airway with incubation and treating secondary injuries such as a hemothorax. After ensuring the patient has a patent airway and other injuries are

Due to the constant risk of sudden rupture or exsanguination urgent treatment is necessary. A patient can either undergo endovascular repair or surgical repair. Endovascular repair is the current gold standard due to increased success rates and lower complications. Patients that are able to undergo endovascular repair without contraindications should proceed with it. Repair should be delayed if there is life threatening intra-abdominal or intracranial bleeding or if the patient is at risk for infection.

Endovascular repair is done by first gaining vascular access usually through the femoral artery. A catheter is inserted to the point of injury and a luminal stent is deployed.

Surgical repair is done by way of a thoracotomy or opening of the chest wall. From this point multiple methods can be used but the most successful methods enable distal perfusion to prevent ischemia.

While waiting for surgery careful regulation of blood pressure is necessary. Systolic blood pressure should be maintained between 100 and 120 mmHg allowing for perfusion distal to the injury but decreasing the risk of rupture. Esmolol is first choice to maintain blood pressure, but if the blood pressure is not within range adding nitroprusside sodium can be added as a second agent. The treatment is similar to what is done for aortic dissections.

If the patient has minimal aortic injury then the patient can be managed non surgically. Rather the patient can be followed with serial images. If the patient does develop a more sever injury including a full thickness injury through the media layer then the patient should be treated with surgery.

Outcomes

Thoracic aortic injury is the 2nd leading cause of death involving both blunt trauma. 80% of patients that have a thoracic aortic injury will die immediately. Of the patients that do make it to be evaluated only 50% will survive 24 hours --JacksLog (talk) 17:47, 27 November 2019 (UTC)

References

MUSC medical writing course

I'm a 4th year medical student editing this article for my medical writing course. Below I have laid out my plan for editing. I will add more to the introduction explaining the thoracic aorta in more detail specifically the anatomy and the function. I will also elaborate on the difference between the thoracic aorta from the remaining portions of the aorta. I plan on adding these sections to the article: Symptoms

• How the patient will present and what are the signs at time of injury that there could be a thoracic aorta injury and include signs that will be apparent on history and physical exam

Mechanism

• Will discuss the different parts of the aorta including the intima, media, and adventitia
• Include details about the different kinds of injuries that can occur including blunt and penetrating trauma and how those impact what injury can occur
• Will discuss the 4 different types of thoracic aortic injury and how they differ

Diagnosis

• Will discuss the gold standard of diagnosis
• Will go through the current accepted algorithm for diagnosing the patient depending on their hemodynamic stability
• Will discuss all of the different imaging modalities that can diagnose thoracic aortic injuries including xray and CT
• I will keep the classification system already in place.

Treatment

• I will discuss the current treatment options and correlate those to the 4 different types of injuries discussed in the mechanism section
• Will elaborate on both surgical and medical management and when each option is chosen depending on the mechanism of injury and the stability of the patient

Outcomes

• Will discuss a systematic review of patient outcomes both from medical and surgical management
• Will also discuss if there tends to be any long term effects from treatment
• In this section I will discuss the rates of mortality when patients present with thoracic aortic injuries

Epidemiology

• For epidemiology I plan on discussing how many traumas lead to these type of injuries

For all of these sections I plan on utilizing medical books, meta analysis, and systematic reviews for all of my sources. --JacksLog (talk) 20:16, 18 November 2019 (UTC)

Very thorough plan! --Emilybrennan (talk) 13:39, 25 November 2019 (UTC)

Peer Review for @Jackslog: Article on "Thoracic Aorta Injury":

• Overall, the article reads well and is well-organized, especially the "Causes" and "Symptoms" sections
• The article has a neutral tone, without biased claims or opinions
• In the "Mechanism" section, there seems to be details about grading of the injury, which I think could be moved to the "Classification" section
• The "Treatment" section has a few spelling errors (e.g., "incubation" instead of "intubation") that need fixing; of the entire article, this section seems to have the most medical terminology without clear lay explanation; I would suggest adding some sub-headings that describe the different options when it comes to treatment (e.g., "open surgical repair" vs "endovascular repair")
• I might expand the "Imaging" section with either some definitions or some images to be able to compare the different modalities you mention and clarify some of the terms for non-medical readers
• References were varied and reputable; there weren't any major areas lacking citations

Paj204 (talk) 21:42, 8 December 2019 (UTC)

Resources

I haven't got the time to create this article just yet but I will get round to it. If anyone wants to beat me to it, feel free. I found PMID 9017797 on PubMed and it looks like a good starting point, a nice, generalised review. —Cyclonenim (talk · contribs · email) 10:57, 27 October 2008 (UTC)

Awesome job! delldot ∇. 07:16, 28 October 2008 (UTC)

As for a picture, there's these; they're really interesting looking, and they're free. They'd make for a great DYK image. But I don't know if pseudoaneurysm counts as an injury, but this case did result from trauma. (You could at least stick these in a complications section). They claim to be "a 64 multislice CT scan", but are they color-enhanced or what? Might be worth shooting an email to the authors. delldot ∇. 07:28, 28 October 2008 (UTC)

I'm not sure a pseudoaneurysm image is best in this case. There are other images available of direct ruptures of the thoracic aorta such as the ones available here (fig 1?) and here. What'd you think? —Cyclonenim (talk · contribs · email) 14:28, 28 October 2008 (UTC)