TRAUMATIC RUPTURE OF THE THORACIC AORTA: TEN-YEAR EXPERIENCE WITH FOLLOW UP

In the past 10 years, 13 cases of acute traumatic rupture of the thoracic aorta were treated at the Dunedin Hospital. Ages ranged from 16 to 77 years, with a mean of 27 years. Twelve of the patients were involved in high speed motor vehicle accidents and one sustained a fall. The diagnosis was suspected in all 13 cases by a widened mediastinum on plain chest X-ray and confirmed by aortography in all cases. Associated injuries were common. The time interval from injury to surgery ranged from 5 h to 16 days, with a mean of 3 days. A Gott Shunt was used in five patients, seven had partial bypass and one had simple aortic cross-clamping. Mean aortic cross-clamp time was 62min. Mortality was 15%, both deaths occurring in the bypass group. There were two cases of paraplegia, one occurring in the bypass group and the other in the patient having simple cross-clamping of the aorta. Follow up was possible in 8 of 13 patients and ranged from 3 months to 10 years, with a mean of 39 months. Delayed death due to heart failure occurred after discharge in a 77 year old man 40 days after operation. The long-term results were satisfactory in all survivors, apart from one poorly rehabilitated paraplegic.     

REPAIR OF TRAUMATIC TRANSECTION OF THE THORACIC AORTA: ESMOLOL FOR INTRAOPERATIVE CONTROL OF ARTERIAL PRESSURE

We report the intraoperative use of esmolol for control of arterialpressure during repair of a traumatic transection of the descendingthoracic aorta. A mean infusion rate of esmolol 50.5 µgkg^–1 min^–1 resulted in a decrease in mean arterialpressure to 63 mm Hg and heart rate to 99 beat min^–1 andwas associated with excellent surgical conditions. The infusionrate of esmolol was titrated easily against mean arterial pressure,which increased rapidly on discontinuing its infusion. Controlof arterial pressure with esmolol was comparable to that achievedwith sodium nitroprusside, but without the reflex tachycardiaor decrease in ?aOl associated with the latter agent. ^*Present addresses: Department of Anaesthesia, St Helier Hospital,Wrythe Lane, Carshalton, Surrey SM5 1AA. Department of Anaesthetics, Charing Cross Hospital, Fulham PalaceRoad, London W6 8RF.     

TRAUMATIC THORACIC AORTIC RUPTURE: INVESTIGATION DETERMINES OUTCOME

Blunt thoracic aortic rupture (TAR) initially presents with subtle signs but is usually fatal if not diagnosed and treated early. Does the diagnostic process affect outcome? The definitive test most widely promoted is thoracic (arch) aortography but is usually only available in major teaching hospitals. Thoracic computerized tomography (CT) scanning is more readily available but its role in diagnosis of TAR is unproven. A retrospective review of trauma databases and medical record indexes over a 7 year period identified 38 patients presenting with TAR at Westmead and Royal North Shore Hospitals in the period 1984–91. Thirteen patients (34%) were dead on arrival or died within 15 min of arrival at either hospital. Five patients (13%) who arrived in cardiac arrest (with suspected TAR) died after immediate thoracotomy (two in the Emergency Department and three in the operating room). Two patients (5%) died from severe head injuries and were not investigated for TAR. Eighteen patients (47%) remained alive long enough for investigation and were considered potentially salvageable. Nine of these survived. Only 13 patients had arch aortography. No patient survived without an aortogram. Five patients had a chest CT scan; aortography followed in four patients. Computerized tomography scans delayed aortography or were misinterpreted. Review of all trauma thoracic (arch) aortograms for the same period at Westmead Hospital revealed a diagnosis of TAR in 7.4%. Blind thoracotomy did not result in survival. Computerized tomography scanning of the chest was of no value in the management of this injury. Early suspicion of possible thoracic aortic rupture demands urgent arch aortography and this remains the diagnostic ‘gold standard’.     

TRAUMATIC RETROPERITONEAL RUPTURE OF THE DUODENUM

A report of six cases of retroperitoneal rupture of the duodenum is presented. A high index of suspicion is necessary to enable early diagnosis to be made and appropriate treatment carried out. Early treatment will prevent the extremely rare, but at present uniformly fatal complication of gas gangrene. Plain X-ray and Gastrografm studies may kelp to elucidate the situation in particular cases, but are no substitute for repeated careful abdominal examination. It is suggested that large doses of penicillin be employed where possible in the management of these cases, in addition to such antibiotic therapy as may be expected to be effective against the usual Gram-negative bowel flora.     

CLOSED TRAUMATIC RUPTURE OF THE DIAPHRAGM

1. The patients suffering from closed traumatic rupture of the diaphragm for the years 1953-63 at the Royal Melbourne Hospital have been reviewed. 2. There were 10 immediate and one delayed ruptures; 6 being on the left and 5 on the right side. 3. The modes of trauma, the commonness of associated injuries and the frequency of thoracic or abdominal signs are recorded. 4. The possible clinical features and the appropriate investigation are pointed out. An analysis of the low rate of correct diagnoses is then made and the importance of an awareness of the condition of chest X-rays has been emphasised.     

TECHNIQUES OF REINFORCING THE ASCENDING THORACIC AORTA

Two techniques of reinforcing the ascending thoracic aorta with Dacron vascular prosthetic material are described. Circular reinforcement has been used in patients with fusiform dilatation of the ascending thoracic aorta in whom it was considered that graft replacement was unsuitable, and also in patients with a thin-walled aorta, where reinforcement was thought to be beneficial in preventing dehiscence of an aortic suture line. The techniques are described in two patients who underwent aortic valve replacement and who had aneurysmal dilatation of the ascending thoracic aorta.     

THE RESULTS OF SURGICAL TREATMENT OF COARCTATION OF THE THORACIC AORTA

A retrospective study of the results of surgical treatment in 124 cases of coarctation of the thoracic aorta is presented. The diagnosis was based on clinical findings alone in 90% of cases. Aortography and/or cardiac catheterization were performed if the diagnosis was in doubt or if other cardiac abnormalities were suspected. Surgical treatment involved either resection with end-to-end anastomosis (114) or some form of grafting procedure (10). The results of treatment have been analysed in terms of operative mortality, late mortality, relief of hypertension, and the incidence of re-stenosis.     

RUPTURE OF THE AORTA IN ROAD CRASH VICTIMS

Traumatic rupture of the aorta following vehicular colllsions is a more frequent occurrence than is generally realized by the members of the medical staff in hospital casualty departments. In the past there has been a tendency to concentrate efforts on other Injuries, especially those relating to the head. With the recognition that 12.7% of all fatal road crash victims have a rupture of the aorta, special attention can be directed to Its early diagnosis. Despite the grave prognosis of this condition, initial rupture may be incomplete, and if emergency surgery is undertaken, the defect may be repaired before it extends and death occurs.     

外伤性肝破裂693例统计分析

为了解近年来外伤性肝破裂的诊治情况，对1990年1月～1995年12月6年间我国部分省区的对所医院收治的外伤性肝破裂患者693例进行了统计分析。693例中男559例，女134例，男女之比为4．17：1，年龄1～77岁，平均39．3岁。闭合性伤占74．5％，交通事故伤占闭合伤的52．9％。伤后4小时内入院者占49．4％，入院时伴失血性休克者占61．9％。术中见上腹腔积血1000ml以上者占61．5％，损伤位于右肝者占70．0％，有合并伤者占19．8％，AAST分类Ⅱ级以上者占45．5％。手术方式以清创缝合及网膜填塞为主，占83．7％，49例行肝部分切除术。术后并发症发生率为22．2％，死亡率为87％。作者认为：进一步建立和健全急救体系、提高基层技术队伍素质及术中对肝外伤的正确处理是提高我国肝外伤救治成功率及降低死亡率的关键。     

DIAGNOSTIC PNEUMOPERITONEUM IN TRAUMATIC RUPTURE OF THE RIGHT DIAPHRAGM

The diagnosis of diaphragmatic rupture following blunt trauma is difficult and often delayed. Introduced pneumoperitoneum can provide important diagnostic information. Its use is illustrated in a case of massive rupture of the right diaphragm where diagnostic pneumoperitoneum was valuable in distinguishing recent rupture from preexisting pathology.     

外伤性延迟性脾破裂

本文报告了外伤性延迟性脾破裂２９例，讨论了其发病规律及临床特点，指出诊断时除依靠病史，临床表现外，应及时进行腹腔穿刺、腹腔灌洗、Ｂｕｓ及ＣＴ检查。治疗以脾切除术为主。