Immediate Evaluation
	Date: 23.01.97 11:40 From: Louis Brusco Jr., M.D. [lb86@columbia.edu] I wanted to get comments on a patient's immediate evaluation. 47 year old male, diabetic, drunk driver, belted driver in 35 mph MVA. Waled out of car, found 300 feet from car. Denied LOC, complaining of chest pain. GCS 15, BP 190/100, P90, RR16. Brought to ER. GCS 15, BP 160/80, P86. Evaluation showed clear c-spine, CXR with bilateral 1st rib fractures, no pneumothorax, mediastinum 6 cm. Labs, Hct, Abg all within normal limits. What to do next? I will follow up with what our residents did in 2 days. -- Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, Critical Care Anesthesiology St. Luke's-Roosevelt Hospital Center, NYC
	Date: 23.01.97 21:08 From: SINGH.SURINDRA_J_@SALEM.VA.GOV I will be very concerned. Bilateral 1st rib fracture means significant impact and possibility of other injuries. Question of mediastinum widening and am immediate CT chest with contrast is indicated. TEE might further help, but in my opinion will not substitute CT. I will also look for other injries and a pneumothorax may be detected on CT, although chest X-Ray is negative. I will look for other injuries to mediastinal structures. CT scan of the head and neck may be considered while getting CT chest, althogh is not mandatory at this time and can be done if clinically suspicious of any injury, but I think I will favor for both. Tell us what your bright residents did. Surindra J. Singh, M.D. VAMC, 1970 Roanoke Blvd. 111-J, Salem, VA 24153
	Date: 24.01.97 02:59 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] CT scan of chest and abdomen, oral and IV contrast, to evaluate retrosternal area and intrabdominal organs to rule out injury not only to aortic area but bilateral subclavians.
	Date: 24.01.97 04:28 From: Keith Wesley [drwesley@primenet.com] In response to drunk driver: Presence of bilateral first rib fractures would signify the possibility of more significant injuries. You did not indicate the level of intoxication. Our institution would perform a CT scan of the chest and lower cervical spine to preclude other injuries. If that was negative and appropiate individuals available to take patient home I would discharge. What Happened? Keith Wesley, MD, FACEP Director, EMS Education & Trauma Care Sacred Heart Hospital Eau Claire, WI
	Date: 24.01.97 06:58 From: dulyatt@medeserv.com.au (David Ulyatt) Hope I'm not to late to comment. We dont usually talk about width of mediastinum's (?mediastina, mediatinata, mediastini) in cm's but in relation to the rest of the CXR. The measurement you quote is not of the aotic knob alone, is it? Clearly #'s of the first ribs and the mechanism/history of the trauma could suggest aortic injury but are secondary signs. If the mediastinum is not widened on the erect CXR (and 6cm's is certainly not wide) then analgesia and observation including repeat CXR is all that is required in this patient. What about the electrocardiogram though, and cardiac enzymes and blood sugar? If he had a qustionably wide mediastinum I would get an aotogram. This may be replaced by TEE but I am not convinced of this in trauma yet. David
	Date: 24.01.97 14:10 From: pmdubois@nbnet.nb.ca (pmdubois) I would proceed to aortogram. If normal, admit and go home to bed. Paul M. Dubois M.D., F.R.C.S.(C), F.A.C.S. General and Thoracic Surgery The Moncton Hospital Moncton, New Brunswick, Canada
	Date: 24.01.97 21:52 From: Stephen Streat [DCCM@ahsl.co.nz] Lou Brusco asked about a patient with trauma, bilateral first rib fractures and 6cm wide mediastinum. I will stick my neck right out and say : If there are any CLINICAL concerns (=concerns by a clinician, not a radiologist) about the possibility that this patient may have an occult great vessel injury he should have an immediate aortogram, not a CT and not both. CT lacks both sensivity and specificity for aortic injury and in most institutions (including our own) will not lead to thoracotomy in and of itself. Our cardiothoracic sugeons insist on prior aortography (so would you if you had operated and found no tear or worse still not operated and had catastrophic rupture). So it seems to me that CT only adds time and money and does not contribute to the critical decision pathway. I know that some people take the view that "if the CT shows no mediastinal haematoma then an aortogram is unnecessary" but I do not believe that the marginal costs ($ and pain) of aortography justify this approach. Remember, if you are not doing 5-10 aortograms for every positive one then you are probably missing it. I take the perhaps rather cynical view that since most trauma centres do a limited number of aortograms per year (in ours where we admit 200 blunt trauma patients, median ISS 29, to ICU every year we do around 12-20) then everyone needs to keep up their skills at the procedure (good pix, no stuffing around, ultraquick result at any time of the day or night) and a certain number of tests must be done to keep the system smooth. My own expected standard of care is that we see good pix from the first run 45 minutes or sooner after the phone call to the radiologist saying "we need an aortogram now". The fact of first rib injury by itself is of no consequence. Similarly the absolute dimension of the mediastinum is less important than whether is appears wide to an experienced clinician who is accustomed to seeing trauma chest xrays. Usually at 6m wide the mediastinum will look normal to everyone in every case but if there is an abnormal contour (what one of my colleagues calls "dogfish head") and the absolute width was still less than say, 8cm, we would still do an aortogram. This is a good story for the sort of mechanism of injury to produce great vessel injury and I would take only one clinical sign (differential pulses, evident haematoma in clavicle region, symptoms of back pain etc) or any of my own suspicion that the mediastinal contour wasn't right to do an aortogram (only). Otherwise, I would sit back and do nothing (except MICLO - masterly inactivity and cat-like observation). Crawls back under rock .. Stephen Streat FRACP Intensivist Department of Critical Care Medicine Auckland Hospital, Auckland, New Zealand
	Date: 30.01.97 06:06 From: "Louis Brusco Jr., M.D." [lb86@columbia.edu] This is in completion of the case I described last week of a guy who was in a drunk MVA, thrown from his car, walking around at the site of the accident. Denied LOC. Came into the ER and evaluation included a CXR which showed bilateral 1st rib fx., and a mediastinum of 6 cm. The residents decided to get a Chest CT (Ken Mattox, please don't cringe). It showed possible blood anterior to the heart and a displaced sternal fracture. Great vessels normal. Patient awake but drunk, complaining of chest pain. An echocardiogram was of poor quality but was read by the fellow as inferior hypokineses, no AI, no effusion. Do you get an Aortogram now? No aortogram was done. He was admitted to the SICU for observation. The next day, he is complining of chest and back pain. All other vitals stable. Do you get an Aortogram now? No aortogram was done. The patient was observed for 2 more days in the SCIU, repeat echo was normal with no pericardial effusion. he was discharged from the hospital on HD#5. I gues the whole point of this is the timing and need for an aortogram. Not being a trauma surgeon, I rely on others opinions. Our two trauma surgeons were split on this patient's magmt., and the one who did not want the aortogram was the attending of record, so one was not done. Any comments? -- Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, Surgical Intensive Care Unit St. Luke's-Roosevelt Hospital Center, NYC
	Date: 30.01.97 12:17 From: Glen Hawkins [glenhawk@ozemail.com.au] Interesting the CT vs Aortogram debate. Obviously the potential rupture would have been contained and I am intrigued as to whether aortography would get all cases in this scenario. I would tend to favour CT with contrast as you could pick up internal injuries of the aorta (contrast in defects) but also with high energy injury, other injuries could also be excluded (eg T spine fractures...the patient did have back pain). With spiral CT this is faster than aortography in most centres in my limited experience. Cheers Glen Glen Hawkins (glenhawk@ozemail.com.au)
	Date: 30.01.97 18:23 From: "Mike Rosenblatt, M.D." [michael.s.rosenblatt@lahey.Hitchcock.ORG] The algorithm for evaluation of this type of injury seems to be somewhat dependent upon the technical capabilities of the CT scan, at least according to the more recent papers in the literature. If you are still stuck with a CT scanner which is not capable of the spiral or helical modes ( I am really not sure what these terms refer to in terms of the machine itself) and can't do dynamic imaging of the aorta with contrast in the lumen, then this patient should have an aortogram. Perhaps someone on the List with a helical or spiral CT capable of dynamic imaging of the aorta can comment on how the technology has changed their algorithm for evaluation of the mediastinum and their usage of aortograms. Michael S. Rosenblatt, M.D., FACS Departments of General Surgery and Surgical Critical Care Lahey Hitchcock Clinic 41 Mall Road Burlington, MA 01805
	Date: 30.01.97 22:4 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] A helical (rapid sequence) dynamic (as the dye is injected through the vein to actually show the aorta) is the right choice. The sternal fracture absorbed most of the force and without a hematoma around the aorta at the ductus level I would not pursue it further. If the transthoracic echo is no good, you can do a transesophageal echo to see the heart function and the ductus area.
	Date: 31.01.97 01:01 From: "Jose Acosta" [miguel@ok.is] You have to be kidding me. Not performing an aortogram on this patient was a grave mistake. That the residents got away with it does not make it right. You probably spent more time, money and risked this patients life just to avoid an aortogram. Who was supervising these residents? Jose A. Acosta M.D., F.A.C.S.
	Date: 31.01.97 01:55 From: Chris Taylor [chris@knakee.demon.co.uk] > Do you get an Aortogram now? well, the guy is drunk .. if he is cooperative enough, I would at this stage. In fact, I wouldn't have done CT or echo: 1) If CT and echo are normal, then your clinical concerns are not going to be alleviated - which makes them rather useless. 2) If they are abnormal, then the cardiothoracic surgeons will want an aortogram anyway. 3) If you have local facilities for CT but none for aortography, but serious clinical concerns over the possiblity of an aortic tear, then the patient should be transferred to a cardiothoracic unit where he can be seen by someone who deals with this sort of thing every day. so in all cases, CT is superfluous - IMHO. > > No aortogram was done. He was admitted to the SICU for observation. >The next day, he is complining of chest and back pain. All other vitals >stable. > > > Do you get an Aortogram now? if it was impossible the night before due to lack of cooperation, yes > > No aortogram was done. The patient was observed for 2 more days in the >SCIU, repeat echo was normal with no pericardial effusion. he was >discharged from the hospital on HD#5. > > I gues the whole point of this is the timing and need for an >aortogram. Not being a trauma surgeon, I rely on others opinions. Our >two trauma surgeons were split on this patient's magmt., and the one who >did not want the aortogram was the attending of record, so one was not >done. > > Any comments? IMHO, a risky :) approach .. perhaps not in this particular case (nothing can substitute clinical assessment in the ER), but overall an expectant management, consistently applied to all patients with bilateral first rib fractures, is likely to miss a significant number of aortic tears that should be dealt with surgically *before* they rupture. -- chris.taylor , Consultant in A&E James Paget Hospital Great Yarmouth, UK
	Date: 31.01.97 08:12 From: dulyatt@medeserv.com.au (David Ulyatt) I don't entirely agree as I am unsure of the indication for CT thorax in this scenario. Do you think we should add this investigation as a routine for immediate evaluation of the patient who has: possible decelleration forces secondary signs (1st rib #'s) of Aortic disruption but a mediastinal width <8cms. Asymptomatic. It is my experience that CT thorax in this context can be an entirely misleading investigation. Negative CT does not exclude aortic disruption. Does anyone know of the incidence of missed aortic injury in the prescence of normal mediastinum on CXR? David
	Date: 31.01.97 09:43 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] 3% of aortic disruptions from blunt trauma have a normal CXR (which is a very small number) and if I remember the data from Weigelt's experience at Dallas correctly, aortograms done for mechanism alone regardless of CXR findings are positive in 3% of cases. Eric Frykberg, M.D. Jacksonville, Fl
	Date: 31.01.97 14:08 From: KMATTOX@aol.com The Resident who wasted a lot of money ordering the CT of the chest should be required to pay the hospital the cost of the CT of the Chest scan. k
	Date: 01.02.97 02:50 From: "Louis Brusco Jr., M.D." [lb86@columbia.edu] > You have to be kidding me. Not performing an aortogram on this > patient was a grave mistake. That the residents got away with it > does not make it right. You probably spent more time, money and > risked this patients life just to avoid an aortogram. Who was > supervising these residents? > > Jose A. Acosta M.D., F.A.C.S. Our director of trauma. -- Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, Surgical Intensive Care Unit St. Luke's-Roosevelt Hospital Center, NYC
	Date: 01.02.97 04:07 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] Obviously you are not aware of Tim Fabian's recent data about a multicenter study of ruptured aortas recommending spiral CT for screening some atypical cases.
	Date: 01.02.97 06:40 From: "Peter H. Bradshaw" 3% is a small number, but it's the second biggest I've seen for normal CXR's in blunt traumatic aortic disruption. An article from the trauma registries of our state (J. Trauma 40(4), 547-556) quotes a 5% incidence, but then refers to several studies showing a 0% incidence of normal CXR's (no mediastinal widening, blunting of the aortic knob, apical capping, deviation of the NG tube or bronchus) in aortic disruption. Peter Bradshaw General/Vascular Surgery Hickory, NC, USA phb@hickorysurgical.com
	Date: 04.02.97 21:59 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] The current literature tends to weigh heavily toward CT being superfluous, therefore dangerous and expensive because it wastes time. In the past 2 years studies have suggested CT for diagnosis of blunt traumatic rupture is no more accurate than the plain CXR, and I have seen NO credible study in which an abnormal CT, if one insists on ignoring the evidence and still do a CT, must not be backed up with a confirmatory aortagram (still another indication of CT's weakness in this setting) Eric Frykberg, M.D. Jacksonville, Fl