A 42-year-old man is brought to the emergency department after a high-speed head-on motor vehicle collision. He complains of severe chest and mid-back pain. His blood pressure is 165/90 mm Hg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 96% on room air. The primary survey is complete; his airway is patent, and breath sounds are equal bilaterally. There is a visible seatbelt sign across his chest. Arrange the following steps in the most appropriate chronological sequence for diagnosing and managing this patient's suspected blunt thoracic aortic injury.
- 1Obtain a portable anteroposterior chest radiograph.
- 2Perform computed tomography angiography (CTA) of the chest.
- 3Initiate an intravenous esmolol infusion.
- 4Perform thoracic endovascular aortic repair (TEVAR).
Answer
The correct sequence is: Obtain a portable chest radiograph, followed by CTA of the chest, then initiate an intravenous esmolol infusion, and finally perform TEVAR.
The appropriate management sequence for suspected blunt thoracic aortic injury begins with a portable chest radiograph as an adjunct to the primary survey. This is followed by a CTA of the chest for definitive anatomical diagnosis. Once the diagnosis is confirmed, strict heart rate and blood pressure control (anti-impulse therapy) must be initiated with a rapidly titratable beta-blocker like esmolol to prevent catastrophic rupture. Finally, definitive surgical management is achieved with TEVAR.
Step-by-Step Solution
Key Concept
The chronological management of suspected blunt thoracic aortic injury (BTAI) in a hemodynamically stable patient involves primary survey adjuncts (chest radiograph), definitive imaging (CTA chest), anti-impulse therapy (beta-blockade), and definitive repair (TEVAR).
Estimated Time:1m 30s