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

Background: 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 intrapleur al aortic rupture before surgical repair. We sought to identify characteris tics of the subpopulation of blunt TAI patients at particular risk for earl y in-hospital death. Methods: The records. of a Level I trauma center were reviewed for the peri od from 1/1/90 through 5/1/00. Fifty-one patients with aortic injury were i dentified. A subgroup was identified with isolated aortic injury. The resul tant study group consisted of 26 patients and included 11 cases of free rup ture (FR) and 15 cases of contained rupture (CR). Data from both groups wer e analyzed for mechanism, abnormal vital signs, initial chest radiographic findings, symptoms, physical findings, time course from injury to rupture o r treatment, clinical outcome, and pathologic findings. Results: All 11 of the FR group died. In the CR group, 14/15 survived. Mech anism in all cases was "high-speed" or "head-on" motor vehicle collision. A ll cases with FR had the mediastinal abnormalities of "grossly widened medi astinum" + hemothorax; 10/11 had an episode of transient hypotension that i nitially responded to fluid resuscitation before their terminal event. In t he CR group, there were a variety of chest radiographic findings, but only one "grossly widened mediastinum," no hemothorax, and no incidences of hypo tension. However, multivariate analysis revealed that the combination of gr ossly widened mediastinum. + hemothorax + transient hypotension was strongl y and uniquely associated with those patients who went on to have free rupt ure (FR group) (p < 0.00001, Fisher's exact test). Conclusion:. For patients exposed to a high-speed decelerative mechanism, t he constellation of "grossly widened mediastinum + hemothorax with transien t hemodynamic instability" appears not only to be highly specific for aorti c injury but also to be a marker of impending sudden death from free ruptur e. This association would seem to warrant immediate surgery in this high-ri sk group without the traditional diagnostic studies.