RUPTURED AORTA AFTER BLUNT CHEST TRAUMA - RAPID DIAGNOSIS BY TRANSESOPHAGEAL ECHOCARDIOGRAPHY WHEN RADIOGRAPHIC AND COMPUTED TOMOGRAPHIC FINDINGS INCONCLUSIVE

History and clinical findings: A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. O n arrival of the emergency physician she was awake and responsive but complained of pain with brusing over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg , heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lu ngs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. Investigations: The EC G showed sinus tachycardia (103 beats/ min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/d l with normal white cell and platelet counts. Clotting tests, serum tr ansaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. Treatment and course: Beca use the haemoglobin level had fallen to 7.7 g/dl within the first 4 ho urs erythrocytes concentrate was infused. The chest radiogram and subs equent computed tomography showed a mediastinal and paraaortic haemato ma of unclear origin. Transoesophageal echocardiography (TEE) demonstr ated rupture of the descending aorta with free floating intraluminal p arts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler ec hocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed an d part of the descending aorta was replaced by a 3 cm dacron tube duri ng an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other i njuries were treated. Conclusion: After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once pro vide details of extent and degree of injury to heart and/or aorta.