James T. Sturm

Traumatic Aortic Rupture: Roentgenographic Indications for Angiography

The principal radiological indication for thoracic aortography following blunt chest trauma has been a widened mediastinum on chest roentgenogram. The presence or absence of sixteen findings on 100 cm anteroposterior supine chest roentgenograms were noted and compared in 47 consecutive patients who underwent aortography following blunt thoracic trauma and 100 patients without trauma. On the basis of our data, we propose six radiological indications for thoracic aortography following chest trauma: mediastinum greater than 8 cm on 100 cm AP supine chest film; tracheal shift to the right; blurring of the normally sharp outline of the aorta; obliteration of the medial aspect of the apex of the left upper lobe; opacification of the clear space between the aorta and pulmonary artery; and depression of the left main bronchus below 40 degrees.

Thoracic aortography following blunt chest trauma

The records of 314 patients who suffered blunt chest trauma and underwent thoracic aortography between 1968 and 1986 were retrospectively reviewed. The patients ranged in age from 7 to 84 years (mean, 37.7 years). There were 255 male and 59 female patients. The majority of injuries were the result of motor vehicle accidents. The most common indication for aortography was a widened mediastinum on chest roentgenogram (83.4%). The aortogram was positive for cardiovascular injury in 19.7% of cases. There were 47 patients with aortic rupture, 15 with subclavian artery disruption, and 1 with traumatic aortic insufficiency. Complications occurred in 1.7% of patients. Two patients sustained groin hematomas and one patient suffered an intimal tear of the ascending aorta from the angiographic catheter. None of the complications required treatment. Aberrant origin of the arch vessels occurred in 0.96% of patients, and ductus diverticulum occurred in 0.64%. There were two false-positive and no false-negative aortograms. It was concluded that thoracic aortography after trauma is accurate and safe.

Risk factors for survival following surgical treatment of traumatic aortic rupture.

Linear discriminate analysis was used to determine the effects of age and Injury Severity Score on survival in 37 consecutive patients treated surgically for traumatic rupture of the thoracic aorta. Pearson product moment correlations were calculated between associated injuries and survival. The age of the injured patients was the only variable that correlated statistically with survival: the lower the patients age, the greater the chance of survival (r = 0.3535; p = 0.016). The severity of the injury, as represented by the Injury Severity Score, showed a tendency toward decreased survival with increasing Injury Severity Score (r = -0.2523; p = 0.066). Specific types of associated injuries did not correlate with survival. Survival rates were not statistically different for patients who underwent cardiopulmonary bypass compared with those in whom a temporary plastic shunt was used (chi-square = 1.72; p = 0.19). We conclude that age is the most significant factor in predicting survival in patients who undergo surgical repair of traumatic aortic rupture.

Brachial plexus injuries from blunt trauma — A harbinger of vascular and thoracic injury

We reviewed the records of 59 patients who suffered brachial plexus injuries following blunt trauma between the years 1974 and 1984. The age of the patients ranged from 2 to 84 years, with a mean of 35.3 years. Forty-five were male patients. The majority of injuries (53%) were caused by motor vehicle accidents. Direct trauma was the mechanism of injury for 33 patients, traction for 18, shoulder dislocation for six, and acromioclavicular separation for two. The injuries occurred on the left side in 33 (56%); the right side in 23 (39%), and bilaterally in three (5%). Eight patients (14%) suffered complete brachial plexus palsies, and 51 (86%) incurred partial palsies. Nine patients (15.2%) presented in shock. Severe associated injuries occurred in this group of patients and included multiple rib fractures, hemopneumothorax, pulmonary contusion, head injuries, and upper extremity fractures. Subclavian artery injuries occurred in three patients, axillary artery in two patients, and an internal carotid injury in one patient. Complete resolution of the palsy occurred in 25 patients, partial resolution occurred in 17 cases, and the brachial plexus palsy remained permanent in nine. Eight patients were lost to follow-up. Brachial plexus injuries frequently occur in association with severe trauma, are usually partial palsies, and resolve partially or completely in two-thirds of cases. In addition, 10% of these patients suffered major vascular injuries and 10% incurred significant chest trauma.

The Management of Subclavian Artery Injuries Following Blunt Thoracic Trauma

The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib.

Arterial injuries of the extremities following blunt trauma.

Thirty-three peripheral arterial injuries were observed in 29 patients following blunt trauma. Motor vehicle accidents were the most common initiating event. The mechanism of injury was fracture or dislocation in 21 patients, acute traction on the extremity in five patients, and contusion in three patients. Pulses were absent distal to the site of arterial injury in all patients. Complete arterial disruption was documented in 19 arteries; intimal or intimal and medial tears were observed in 10 arteries. Four arteries not surgically explored. If possible, debridement and primary anastomosis was the preferred method of revascularization. Saphenous vein interposition grafts were the second choice. Five amputations, four major and one minor, were required. Although patient vascular reconstructions may be uniformly achieved, long-term functional results are frequently affected by the duration of limb ischemia before revascularization, and concomitant injuries to bone, nerve, and soft tissue.

Does Sternal Fracture Increase the Risk for Aortic Rupture

We retrospectively reviewed the records of 99 patients who suffered sternal fractures between 1968 and 1987. Patients ranged in age from 5 to 86 years. The most common cause of injury was a motor vehicle accident. The 99 patients were compared with a concurrent series of 2,106 patients with chest injuries and no sternal fractures. Traumatic aortic rupture occurred in 2 of 99 patients with sternal fractures (2%) and in 75 of 2,106 patients without sternal fracture (3.6%). This difference was not statistically significant by the Fisher exact test (p = 0.326). We conclude that traumatic aortic rupture does not occur more commonly in patients with sternal fracture when compared with other patients with blunt chest injuries.

Brachial Artery Disruption following Closed Elbow Dislocation

Although elbow dislocation occurs frequently, associated brachial artery injury is rare. Adequate treatment of this injury includes prompt arteriography, reduction of the dislocation, vascular repair, and transarticular fixation of the reduction. A case report and review of the literature are presented.

HIV prevalence in a midwestern emergency department.

STUDY OBJECTIVE To determine the prevalence of human immunodeficiency virus (HIV) seropositivity of patients 15 years of age and older in our emergency department. DESIGN HIV status was determined anonymously, and the seroprevalence rate was calculated. The 95% confidence intervals also were calculated. Twenty demographic and predictor categorical variable were cross-tabulated with HIV status to determine associations. Only gender and male homosexual preference were significantly associated by Fishers exact test. TYPE OF PARTICIPANTS Excess serum samples from 454 randomly selected patients 15 years of age and older who required venipuncture for their ED evaluation were included in the study. MEASUREMENTS AND MAIN RESULTS Of the 454 serum specimens, six (1.32%) were positive for HIV. The 95% confidence interval was from 0.27% to 2.37%. All six positive patients were men. The only statistically significant risk factors associated with HIV seropositivity were male sex (P = .00112) and male homosexual preference (P = .0000). CONCLUSION HIV seropositivity occurs in 1.32% of our ED population over the age of 15 years. The only factors that correlate with HIV seropositivity are male homosexual preference and male sex.

Injuries associated with fractures of the transverse processes of the thoracic and lumbar vertebrae.

The records of 92 patients who sustained fractures of the transverse processes of thoracic or lumbar vertebrae between 1976 and mid-1982 were reviewed. The majority were injured in motor vehicle accidents. Trauma to abdominal viscera occurred in 19 patients including hepatic injuries in six, splenic injuries in 12, and colonic injuries in five. Hematuria was present in 51 patients and five of 51 had urinary tract injury requiring operative treatment. None of 34 patients without hematuria incurred anatomic disruption of the urinary tract. Thirty-two patients suffered other associated injuries, including thoracic, orthopedic, maxillofacial, and cerebral trauma. Fifteen patients incurred other spinal injuries. The overall mortality was 11% (ten patients). The mean Injury Severity Score in the 92 patients was 13.9. The frequency of abdominal visceral trauma with this bony injury (19/92-21%) suggests great energy expenditure and should alert physicians to seek other severe injuries.