78yo female pedestrian versus car.
She was hit to the legs at >60kph and then thrown several meters. She was intubated at the scene due to decreasing GCS and transported to ED via HEMS.
She had no evidence of chest injuries. She had an epigastric bruise extending across the abdome, L elbow and thumb bruising and R open distal tib fib fractures. EFAST was negative. No other injuries were noted. She had normal LL pulses.
She was stable during transport except for a drop in SBP to 60 just prior to landing. A unit of pack cells was started by HEMS.
In the ED, she initially stabilised after the unit of pack cells, but then continued to have episodes of hypotension. ED cardiac ultrasound revealed a hyperdynamic LV, small collapsing IVC. Further pack cells were given but the source of bleeding was still indeterminate. Frustratingly, repeat EFAST was still negative!!
I didn't think to look at the aorta!
CTs revealed no injuries in the chest, no organ injury in the abdomen. However, the spleen was variegated with a prominent splenic artery ?splenic artery dissection with associated infarction. The abdominal aorta was not dilated but it was surrounded 180 degrees with ?haematoma: suggesting ? traumatic aortic dissection.
The patient was brought back to ED. She had ongoing episodes of hypotension which responded to fluid resuscitation.
These are her US images done upon return to ED.
Trans aorta (mid) showing a normal sized aorta anterior to the vertebra with surrounding haematoma (see below).
colour doppler images showing blood flowing into haematoma (see below).
CT image of dissection
Isolated abdominal aortic dissection is rare (1). There are only a handful of case reports of abdominal aortic dissection as a sequelae of blunt abdominal trauma (2,3). It has been described post MVA (3) and even Heimlich manoeuver (4) in elderly and young patients. It is most often picked up by CT. US diagnosis in the ED in the setting of trauma has not been described.
Some EFAST courses recommend starting the EFAST with a view of the aorta. Maybe in the patient with unexplained hypotension post abdominal trauma ultrasound images of the abdominal aorta should be considered.
1. Trimarchi S, Tsai T, Eagle KA, et al. International Registry of Acute Aortic Dissection (IRAD) investigators. Acute abdominal aortic dissection: insight from the International Registry of Acute Aortic Dissection (IRAD). J Vasc Surg 2007;46:913–19.
2. Berthet JP, Marty-Ané CH, Vecrapen R, Picard E, Mary H, Alric (2003) Dissection of the abdominal aorta in blunt trauma: endovascular or conventional surgical management? J Vasc Surg 38:997–1004
3. Martí M, Pinilla I, Baudraxler F, Simón MJ, Garzón G. A case of acute abdominal aortic dissection caused by blunt trauma. Emerg Radiol (2006) 12: 182–185.
4. Desai SC, Chute DJ, Desai BC, Koloski ER. Traumatic dissection and rupture of the abdominal aorta as a complication of the Heimlich maneuver. J Vasc Surg. 2008 Nov;48(5):1325-7