From the Guidelines
For a patient with blunt chest trauma resulting in hematoma, rupture of the descending thoracic aorta, and mediastinal hematoma, the recommended management is option B: Delayed repair. The initial focus should be on stabilizing the patient with aggressive blood pressure control using beta-blockers (such as esmolol 50-300 mcg/kg/min IV or metoprolol 5mg IV every 5 minutes up to 15mg) to maintain systolic blood pressure between 100-120 mmHg and heart rate below 100 beats per minute, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. This approach, known as permissive hypotension, reduces shear forces on the injured aorta while maintaining adequate organ perfusion.
Concurrent management should include:
- Resuscitation
- Treatment of associated injuries
- Thorough diagnostic evaluation with CT angiography, which is recommended for cases of TAI suspicion 1 Once the patient is hemodynamically stable and other life-threatening injuries are addressed, definitive repair of the aortic injury can proceed, typically within 24-72 hours.
The 2022 ACC/AHA guideline for the diagnosis and management of aortic disease also supports the use of delayed repair in patients with ruptured TAAA, highlighting the importance of a Multidisciplinary Aortic Team in achieving low mortality rates 1. However, the most recent and highest quality study, the 2024 ESC guidelines, recommends delayed repair for traumatic aortic injury, with immediate repair only in cases of severe aortic injury (grade 4) 1.
It is essential to note that patients with free rupture, expanding hematoma, or hemodynamic instability despite medical management require immediate surgical intervention. The management of blunt traumatic aortic rupture is evolving, and careful blood pressure control has been shown to be safe in many patients, allowing for delayed repair once other injuries have been stabilized, as reported by Svensson et al and Pate and colleagues 1.
From the Research
Management of Blunt Chest Trauma
The management of a patient with blunt chest trauma, hematoma, rupture of the descending thoracic aorta, and mediastinal hematoma is complex and requires careful consideration of several factors.
- The patient's condition is critical, and immediate attention is necessary to prevent further complications.
- Studies have shown that endovascular repair of blunt thoracic aortic injuries is associated with lower mortality rates compared to open repair 2.
- Delayed repair of blunt thoracic aortic injuries may confer a mortality advantage, but this approach should be individualized based on the patient's condition and other factors 3.
- The use of noninvasive ventilation and airway pressure release ventilation may be beneficial in managing patients with blunt chest trauma 3, 4.
- Mediastinal hematoma can be a potentially fatal condition that may be overlooked by traditional Focused Assessment with Sonography for Trauma (FAST) 5.
Treatment Options
The treatment options for a patient with blunt chest trauma, hematoma, rupture of the descending thoracic aorta, and mediastinal hematoma include:
- Immediate repair: This approach may be necessary in cases where the patient's condition is critical, and delayed repair is not feasible.
- Delayed repair: This approach may be considered in cases where the patient's condition is stable, and the risk of complications is lower.
- Repair within 6 hours: This approach may be considered in cases where the patient's condition is stable, and the risk of complications is lower.
- Endovascular repair: This approach has been shown to be associated with lower mortality rates compared to open repair 2.
- Open repair: This approach may be necessary in cases where endovascular repair is not feasible or has failed.
Considerations
When managing a patient with blunt chest trauma, hematoma, rupture of the descending thoracic aorta, and mediastinal hematoma, several considerations should be taken into account, including: