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Mechanistic Deep Dive
Aortic Deceleration Injury
- Aorta fixed at ligamentum arteriosum (isthmus)
- During deceleration: aorta swings, isthmus is âanchor pointâ â tear
- 50% fatal at scene
- Survivors often have a contained hematoma
- Intimal tear â false lumen â aneurysm or rupture
Cardiac Tamponade Physiology Refresher (Ch283)
- Acute pericardial fluid â â pressure â impaired filling
- Even small volumes (< 100 mL) cause tamponade if acute
- Beck triad: hypotension + JVD + muffled heart sounds
- Pulsus paradoxus
RV Anatomic Position
- Most anterior chamber
- Closest to chest wall
- Most commonly injured in blunt trauma
Recent Trials & Updates
TEVAR vs Open Repair Aortic Transection
- Multiple studies + meta-analyses 2010s-2020s
- TEVAR: lower mortality + morbidity
- Now standard of care for most
Damage Control Resuscitation
- Avoid crystalloids; use blood products 1:1:1 (RBC:plasma:platelets)
- Permissive hypotension during initial resuscitation
- Tranexamic acid (TXA) for major trauma (CRASH-2)
REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta)
- For non-compressible torso hemorrhage
- Limited role; trials ongoing
- May save selected patients
ECPR (ECMO-CPR) for Traumatic Arrest
- Limited role
- Highly selected centers
High-Yield Specialist Points
Trauma + Anticoagulant Reversal
- Warfarin: 4-factor PCC + vitamin K
- DOAC: andexanet alfa (Xa inhibitor); idarucizumab (dabigatran)
- Aspirin: platelet transfusion (debated, NSAID-induced trauma)
Multidisciplinary Approach
- Trauma surgery
- Cardiothoracic surgery
- Anesthesia
- Critical care
- Cardiology
- Interventional radiology
- Vascular surgery
Pediatric Trauma Pearls
- Different mechanism (bike handlebars)
- Greater chest compliance â may have severe internal without external injury
- AED + CPR same as adults
Late Complications of Cardiac Trauma
- Pericarditis / pericardial effusion (post-traumatic, weeks-months)
- Constrictive pericarditis (chronic)
- Pseudoaneurysm
- AV block
- Late valvular dysfunction
Cardiac Imaging Post-Trauma
- Echo within 24 hours
- Repeat echo 1-3 months if injury suspected
- CMR for late complications
- CT for vascular injury
Iatrogenic Coronary Dissection
- During PCI ~ 0.1-0.5%
- Treatment: stenting at proximal end, observation if minor
- Re-do PCI if extending
Pacemaker / Lead Perforation
- ~ 1% with active fixation leads
- Late perforation: weeks-months
- Echo + lead repositioning surgery
- Pericardial drainage if tamponade
Endomyocardial Biopsy Risk
- Perforation < 1% with experienced operator
- TR + coronary artery injury rare
Trauma + Aortic Dissection (Different from Spontaneous)
- Type B usually
- Younger patient
- Surgical / TEVAR considered
- Similar mortality if untreated
Pearls
- Blunt cardiac contusion: troponin (best NPV at 4-6 hr), ECG, echo
- Cardiac rupture: FAST â emergent surgery; RA most common
- Aortic transection: CXR signs (widened mediastinum) â CT angio â TEVAR + esmolol
- Valvular blunt injury: TV most common
- Penetrating: ED thoracotomy for peri-arrest stab; OR repair for stable
- Iatrogenic: cath, lead, biopsy perforation; reverse AC + pericardiocentesis if tamponade
- Damage control + TXA + permissive hypotension in major trauma
- TEVAR > open for aortic injury