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Difficulty: MediumCardiothoracic and Vascular Surgery

A 34-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was found 30 feet from his motorcycle and was unresponsive at the scene. Upon arrival, his temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respiratory rate is 28/min. He is immediately intubated for airway protection. A focused assessment with sonography for trauma (FAST) examination shows no intraperitoneal or pericardial fluid. The pelvis is mechanically stable to anteroposterior and lateral compression. A supine anteroposterior chest radiograph reveals a widened mediastinum, obliteration of the aortic knob, and depression of the left mainstem bronchus. Despite the rapid intravenous infusion of 2 liters of warmed crystalloid and 2 units of type O-negative packed red blood cells, his blood pressure remains 78/42 mm Hg. Which of the following is the most appropriate next step in management?

  1. Immediate transport to the operating room for transesophageal echocardiographyAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Intravenous administration of labetalol
  4. D
    Transthoracic echocardiography in the emergency department
  5. E
    Transfer to the intensive care unit for permissive hypotension

Answer

Immediate transport to the operating room for transesophageal echocardiography
This patient presents with hemorrhagic shock and radiographic signs highly suspicious for blunt thoracic aortic injury (BTAI), such as a widened mediastinum and obliteration of the aortic knob following a rapid deceleration mechanism. Because he remains hemodynamically unstable despite aggressive fluid and blood product resuscitation, he cannot safely be transported to the radiology suite for a computed tomography (CT) scan. The most appropriate next step is immediate transfer to the operating room. There, the anesthesia team can rapidly perform transesophageal echocardiography (TEE) to confirm the diagnosis of BTAI while the surgical team simultaneously prepares for an emergent thoracotomy or thoracic endovascular aortic repair (TEVAR).

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient remains profoundly hypotensive (78/42 mm Hg) despite receiving 2 liters of crystalloid and 2 units of packed red blood cells.
Hemodynamic stability is the primary factor determining whether a trauma patient can safely leave the resuscitation bay for advanced imaging.
2
Analyze the mechanism of injury and radiographic findings.
A high-speed deceleration mechanism combined with a widened mediastinum and obliterated aortic knob strongly suggests a blunt thoracic aortic injury (BTAI).
Identifying the likely source of hemorrhage directs the subsequent diagnostic and therapeutic interventions.
3
Determine the safest diagnostic and management modality for an unstable patient with suspected aortic injury.
Transesophageal echocardiography in the operating room is chosen over CT angiography.
Unstable patients cannot be safely transported to a CT scanner. TEE can be performed concurrently with surgical preparation in the operating room.

Key Concept

In hemodynamically unstable trauma patients with suspected blunt thoracic aortic injury, computed tomography is contraindicated. Diagnosis should be established in the operating room using transesophageal echocardiography, allowing for immediate surgical repair.
Estimated Time:1m 15s
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Topics

Cardiothoracic and Vascular Surgery

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