Case Study: A 61-Year-Old Male with Chest and Back Pain Following Blunt Trauma
Timothy A. Plerhoples, MD, MPH ∙ John Sherck, MD ∙ John Brawley, MD ∙ Ralph S. Greco, MD
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Citation: Plerhoples TA, Sherck J, Brawley J, Greco RS. Case Study: A 61-year-old male with chest and back pain following blunt trauma. J Surg Radiol. 2011 Jan 1;2(1).
Received: October 1, 2010; Accepted: November 17, 2010; Published: November 23, 2010 Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
Contents
- Findings
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Presentation
A 61-year-old man was brought into our Level I trauma center by EMS as a pedestrian struck by a vehicle. Witnesses reported the vehicle was moving at 25 mph when it impacted the pedestrian, dragging him several feet and eventually lodging him under a guardrail. After several minutes of unconsciousness, the man was extricated by EMS. He awoke, but was confused, with stable vital signs, and complained of chest and back pain.
Figure 1. One image from a contrast CT scan obtained after primary and secondary trauma evaluation.
Findings
By the time he arrived to the trauma bay, he had a blood pressure of 90/61, pulse of 85, respiratory rate of 20, and venous oxygen saturation of 97% on room air. His airway was intact, breath sounds were equal bilaterally, he had good radial and dorsalis pedis pulses, he was moving all extremities, and he had a Glasgow Coma Scale of 14 (one point deduction for confused language).
A Focused Assessment with Sonography for Trauma (FAST) was negative, and physical exam was remarkable only for mid-lumbar spine tenderness with an overlying abrasion, a left elbow abrasion, and left hip tenderness. Two liters of saline were given; his blood pressure improved to 124/67. After chest and pelvis plain films were obtained and deemed negative, the decision was made to bring him to the CT scanner.
Figure 2. Intra-operative angiogram obtained prior to placement of endograft cuff.
Diagnosis
While well protected in the retroperitoneum, the abdominal aorta may be injured by blunt force since it is fixed in position by the vertebral column and lumbar vessels. Today’s trauma surgeons see far fewer blunt force-caused injuries to the abdominal aorta than to the thoracic aorta due to their high on-scene mortality, accounting for less than five percent of all injuries to the aorta.1 A majority are seen in patients involved in motor vehicle accidents either as passengers or as drivers. The incidence of such injuries is rising, likely due to the required use of seatbelts in most states.2 Injuries may range from simple contusion to frank rupture, and include intimal disruption with dissection, intramural hematoma, and pseudoaneurysm. Direct force tends to result in laceration from associated vertebral fractures. Indirect force stems from compression between organs and the vertebral column, or deceleration causing shearing forces between free and relatively fixed segments of the aorta (more common in the thoracic aorta).
In terms of location, over 90% occur in the infrarenal aspect, with most of the remaining occurring near the insertion of the inferior mesenteric artery.1 It remains debatable whether atherosclerosis plays a role, with pathogenesis related to weakening of the intima with a loss of elasticity and compliance.3
Early clinical signs and symptoms of blunt injury to the abdominal aorta include abdominal pain, acute arterial insufficiency, acute abdomen, weakness/paralysis/paresthesia, abdominal wall contusion/defect, and back pain. Delayed signs that may suggest an injury include abnormal peripheral pulses or claudication, an abdominal mass, and an abdominal bruit.4 Approximately one third of cases reported in the literature resulted from delayed diagnosis, due either to veiled vascular symptoms or to concurrent visceral lesions.5
Over the past few decades, catheter-based techniques have been increasingly used in the management of the trauma patient, including embolization of pelvic vessels or solid organs. Despite this history, the use of endovascular techniques in the management of acute traumatic vascular injuries has been afforded little attention in the literature. There is more recent interest in using “less invasive” techniques especially in stable patients with concurrent head or thoracic injuries,6 although many surgeons are wary of using anticoagulation in such patients. While a low incidence limits its general use, endovascular repair options should be considered for hemodynamically-stable blunt force trauma patients with abdominal aortic injuries.
Management
Our patient was taken to the operating room for angiography, which revealed the infrarenal pseudoaneurysm at the level of the third lumbar vertebral body. An endovascular pseudoaneurysm repair was done using an endograft cuff with good result. The patient remained in the intensive care unit overnight, and was ultimately discharged from the hospital four days later.
References
- Roth SM, Wheeler JR, Gregory RT, Gayle RG, Parent FN, Demasi R, Riblet J, Weireter LJ, Britt LD. Blunt Injury of the Abdominal Aorta: A Review. The Journal of Trauma: Injury, Infection, and Critical Care. 1997;42(4):748-755.
- Katsoulis E, Tziopis C, Sparks I, Giannoudis PV. Compressive blunt trauma of the abdomen and pelvis associated with abdominal aortic rupture. Acta Orthop. Belg. 2006;72:492-501.
- Beless DJ, Muller DS, Perez H: Aortoiliac occlusion secondary to atherosclerotic plaque rupture as the result of blunt trauma. Ann Emerg Med. 1990;19:922-924.
- Lock JS, Huffman AD, Johnson RC. Blunt Trauma to the Abdominal Aorta. The Journal of Trauma, 1987;27(6):674-677.
- Solovei G, Alame A, Bardoux J et al. Paraplegia and dissectionof the abdominal aorta after closed trauma. A propos of a case. Current review of the literature (1982-1993). J Chir (Paris) 1994;131:236-244.
- Starnes BW, Arthurs ZM. Endovascular Management of Vascular Trauma. Perspect Vasc Surg Endovasc Ther. 2006;18:114.
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