GA5-94
Vessel tearing car accidents
1Kryzman N, 2Cortland E, 3Campbell B
1University of Connecticut ~ School of Medicine, Farmington, Connecticu, United states; 2Connecticut Children's Medical Center, Hartford, CT, USA; 3Connecticut Childrens Medical Center, Hartford, CT, United states
Heart
Case: 7-year-old boy who presents to the emergency department with respiratory distress after a motor vehicle crash. Patient was obtunded in the ED and intubated for respiratory compromise using etomidate and succinylcholine. Chest X-Ray showed widening of the mediastinum and a left-sided pleural effusion. A CTA of the chest revealed bilateral pulmonary contusions, a left hemothorax with associated mediastinal shift to the right, and evidence of aortic injury with active extravasation of contrast. He was emergently brought to the operating room for further management. Standard ASA monitors were connected, 2 large bore IVs were placed, and a 22-gauge arterial line was placed in the right radial artery. Left-sided chest tube was placed and a large amount of frank blood was evacuated. He became acutely hypotensive with ongoing output from the chest tube. Massive transfusion protocol was activated and a thoracotomy was performed to control the blood loss. A sponge stick and vascular clamp across the aorta were used to temporize the bleeding while we transported the patient to a hybrid OR at the adjacent adult hospital. ABG and chemistry revealed a significant anemia and hypocalcemia, which were both correct intraoperatively. The surgical team gained vascular access via the right femoral artery and placed an endovascular graft across the transected aorta. The patient was transferred intubated to the PICU postoperatively and was extubated on POD2. The patient improved over the following days and was discharged on POD 9.
Discussion:
Blunt traumatic aortic injury from non penetrating trauma is rare in children compared to adults, with population studies reporting an incidence of 1%. The most common mechanism are motor vehicle accidents. Mortality rate is high, with studies reporting 33-35% in pediatric patients. CTA of the chest in our patient showed pseudoaneurysm of the aorta at the level of the ligamentum arteriosum consistent with aortic transection. The proximal aorta is mobile as compared with the descending aorta and the point of maximal shearing stress in sudden decelerations is the transition point. Adult studies suggest that endovascular repair have a lower mortality rate than open repairs. This mode of intervention was successful in our patient and there are several other case reports of positive outcome in children with endovascular repairs.
Anesthetic implication for traumatic aortic injury relate to induction technique, hemodynamic monitors, and maintenance of adequate perfusion. For our patient, who was obtunded with inadequate respirations and assumed full stomach, rapid sequence induction was utilized to secure the airway. On arrival to the ED the patient had been typed and cross for blood products. In the OR, given the CTA findings, large hemodynamic shift and heavy blood loss were expect. An arterial line was placed for monitoring and laboratory blood draws. Both perfusion pressure and oxygen carrying capacity are vital for maintenance of adequate end organ perfusion. Our threshold for transfusion was low and massive transfusion protocol was activated early in the case. The patient's mean arterial pressure stayed above 65mm Hg throughout the case without the need for vasopressors.
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