TRAUMATIC THORACIC AORTIC RUPTURE IN THE PEDIATRIC-PATIENT

Background. Traumatic thoracic aortic rupture is a rare injury in the pediatric patient. Experiences with thoracic aortic rupture in patient s less than 17 years of age are needed to help identify factors that c an influence injury occurrence, diagnosis, management, and outcome. Me thods. Between July 1989 and December 1995, 6 children were treated op eratively for thoracic aortic rupture from blunt trauma at a level I p ediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography ( 2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiop ulmonary bypass (2 patients) and clamp and sew technique (4). Results. Aortic ruptures were complete transections at the ligamentum arterios um in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central n ervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearin g seat belts, and 2 of these were ejected. The average time from injur y to the operating room was 17.6 hours (range, 5 to 48 hours); the tim e from diagnosis to the operating room exceeded 5 hours with aortograp hy and was less than 3 hours with chest computed tomography and transe sophageal echocardiography. Each diagnostic modality accurately identi fied an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 min utes (range, 16 to 45 minutes), respectively. One patient with preoper ative paraplegia regained partial function; there were no other patien ts with paraplegia. There were no deaths. All patients are alive 2 mon ths to 7 years after repair. Conclusions. The multiply injured child w ith severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the c hild involves selective performance of chest computed tomography and t ransesophageal echocardiography. Our experience suggests that the mech anism of injury, the duration to diagnosis of an aortic injury, and fa ilure to use seat belts may contribute to morbidity. A high index of s uspicion and a systematic approach to the diagnosis and to the managem ent strategy for injuries to the thoracic aorta can contribute to a go od outcome in those few children who survive the injury.