Kimberly M. Hendershot

Evaluation and Management of Blunt Traumatic Aortic Injury: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Fracture of the Scapula with Intrathoracic Penetration in a Skeletally Mature Patient

To our knowledge, intrathoracic displacement of a fractured scapula has only been described in two reports involving adolescents1,2. We present the case of a skeletally mature adult with a scapular fracture that penetrated the thoracic cage without causing a pneumothorax. We speculate as to how the adult scapula can deform in a manner consistent with this rare injury. As the patient had advanced Alzheimer disease, the family consented to the publication of data concerning this case. A seventy-two-year-old woman with Alzheimer disease was brought to the emergency department at our hospital after being struck by a car while crossing the street. Physical examination revealed deformity of the right tibia and tenderness over the posterior aspect of the left shoulder. There was no evidence of acute respiratory distress or shortness of breath, and the partial oxygen saturation on room air was 98%. Neurovascular examination revealed normal findings in all four extremities. A comminuted midshaft right tibial fracture was diagnosed on plain radiographs. The initial chest radiograph demonstrated multiple left-sided rib fractures without any obvious hemothorax or pneumothorax (Fig. 1). There was suspicion of a left scapular fracture. A computerized tomographic scan of the chest was performed (Figs. 2, 3, and 4). Three-dimensional reconstruction demonstrated a comminuted scapular body and neck fracture. There was an incomplete sagittal split immediately below a transverse fracture that separated the superior and inferior aspects of the scapula (Figs. 3 and 4). The proximal aspect of the lower lateral column was noted to be trapped …

Splenic artery-to-superior mesenteric artery bypass for chronic mesenteric ischemia--a case report.

Chronic mesenteric ischemia (CMI) is a serious vascular condition that if left untreated may progress to acute ischemia resulting in bowel necrosis and high surgical morbidity/mortality rates. Elective intervention has been shown to prevent this progression and relieve symptoms. Current open surgical intervention involves arterial bypass using a vein or synthetic graft conduit with the inflow originating from the aorta or iliac artery. In some circumstances, the splenic artery provides an additional treatment option for revascularization of the superior mesenteric artery. In certain cases, the splenic artery has several advantages over traditional surgical options. The splenic artery is an arterial conduit much like the internal mammary artery used in coronary artery bypass grafting. These grafts are known for their long-term patency and in selected clinical circumstances are preferred over venous grafts. Because the splenic artery has a natural inflow, only a single vascular anastomosis at the outflow vessel (the SMA) is necessary. This lessens the risk of anastomotic stenosis by decreasing the number of anastomoses created and it makes the procedure shorter in duration. The fact that the inflow is provided by the splenic artery makes cross-clamping of the aorta unnecessary, thereby lessening the risk of producing cardiac ischemia and declamping hypotension. A disadvantage is the risk of splenic ischemia with the possible need for splenectomy. The majority of individuals will have adequate collateral supply to the spleen via the short gastric arteries. The risk to the patient of splenectomy versus the benefits of a less complicated arterial reconstruction with avoidance of aortic cross-clamping must be weighed on a case-by-case basis. Preventing the progression to acute mesenteric ischemia with its increased mortality by timely restoration of adequate vascular supply is an important principle in treating patients with CMI. Controversy still exists over the best treatment option for these patients, whether it be antegrade versus retrograde bypass, single-vessel versus multivessel reconstruction, or open surgical repair versus endovascular intervention. In selected patients, the use of the splenic artery can be considered as an additional option for arterial reconstruction of the SMA.

Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Background:Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. Methods:A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. Results:Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. Conclusion:There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients. (J Trauma Acute Care Surg. 2015;78: 125–135.Level of Evidence: Systematic reviews and meta-analyses, level III.