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Traumatic aortic injuries in the pediatric population
Journal of Pediatric Surgery (2008) 43, 1077–1081
www.elsevier.com/locate/jpedsurg
Traumatic aortic injuries in the pediatric population Scott A. Anderson, Mathew Day, Mike K. Chen, Thomas Huber, Lawrence L. Lottenberg, David W. Kays, Elizabeth A. Beierle⁎ Department of Surgery, PO Box 100286, JHMHSC, Gainesville, FL 32610-0286, USA Received 30 January 2008; accepted 9 February 2008
Key words: Pediatric; Trauma; Abdominal; Thoracic; Aorta; Vascular; Injury
Abstract Background/Purpose: Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period. Methods: After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded. Results: There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home. Conclusions: Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained. © 2008 Elsevier Inc. All rights reserved.
Traumatic injury remains the most common cause of death and disability in the pediatric population. It is estimated that 20,000 children die each year from traumatic injuries [1]. Despite increases in the incidence of penetrating trauma, blunt trauma remains the most common mechanism of injury in children, including motor vehicle crashes, falls, and vehicle vs pedestrian crashes. Presented at the 59th Annual Meeting of the Section on Surgery, American Academy of Pediatrics, San Francisco, CA, October 25-27, 2007. ⁎ Corresponding author. Tel.: +1 352 392 3718; fax: +1 352 392 9081. E-mail address: [email protected] (E.A. Beierle). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.02.030
Traumatic aortic injuries result in significant morbidity and mortality. The management of aortic injuries in adult trauma patients has been well established, based upon both military and civilian experiences. In fact, the Eastern Association for the Surgery of Trauma has published best practice guidelines for the diagnosis and treatment of traumatic thoracic aortic injuries in adults that are available on the Internet [2]. Vascular injuries in children are much less common and are primarily iatrogenic injuries sustained during catheterization procedures or traumatic injuries to the vasculature of the extremities. Most reports of aortic injuries in children are limited to case reports or small series [3-5],
1078
S.A. Anderson et al.
Table 1 Hemodynamics, hemoglobin, and GCS at presentation Patient
Systolic BP (mm Hg)
Mean arterial pressure
Heart rate (beats/min)
Hgb (g/dL)
GCS
1 2 3 4 5 6 7 8 9 10 11
115 147 101 124 137 110 157 134 128 130 110
83.7 106.3 71 86 82.3 78.7 94 94 92 92 69.3
116 136 96 77 95 130 119 96 114 116 105
12.1 12 14 12 11.6 15.2 13 15 14.1 12.6 11
15 15 15 12 15 12 15 13 15 15 15
Hgb indicates hemoglobin.
and there is an even greater paucity of data available pertaining to the injury of the abdominal aorta in children. The purpose of this report is to investigate the patient demographics, mechanisms of injury, associated injuries, treatment of aortic injuries, and outcome of pediatric patients with these injuries cared for at a single institution.
1. Methods Approval for this study was obtained from the Institutional Review Board at the University of Florida. Both the hospital and pediatric surgery databases were queried for all pediatric patients seen at our institution who were younger
Table 2
than 20 years and had sustained traumatic injury to either the thoracic or abdominal aorta, including The International Classification of Diseases, Ninth Revision, Clinical Modification (Sixth Edition), codes 901.0 to 901.0, over a 10-year period from January 1996 to July 2006. A retrospective review of the hospital and clinic charts of these children was performed. Children with injuries limited to a major branch of the aorta, such as the carotid, mesenteric, renal, or iliac arteries, were excluded from review. All children were evaluated by the Pediatric Surgery or Trauma Surgery services at the University of Florida. Data regarding patient demographics, mechanism of injury, hemodynamic status at presentation, diagnostic modalities, specific vascular diagnostic modalities, associated injuries, therapy, complications, and outcomes were gathered. Where appropriate, data are reported as mean ± standard error of the mean.
2. Results The results are presented in tabular form in Tables 1-3.
2.1. Patient demographics and mechanism of injury There were 11 patients who met the aforementioned criteria. The mean age of the patients was 14.3 ± 1.2 years (range, 7-19 years). The youngest patient was 7 years, and only 3 of the patients were older than 16 years. Most of the children were male (n = 8, 72%), and most were injured as occupants of a motor vehicle crash (n = 8, 72%). The other
Traumatic thoracic aortic injuries
Patient Age (y) Sex Mechanism of Injury
Restraint Diagnosis
1
13
M
BCA, no helmet –
2
16
M
MVC
No
3 4
13 19
M F
ATV, no helmet MVC
– No
5 6
15 17
M F
MVC MVC
No No
7
18
M
Fall
–
CT, TEE
Repair
Associated injuries
Rib fx, pulmonary contusion, pneumothorax, femur fx, acromion fx, liver laceration, kidney contusion CT, aortogram Yes, graft Femur and bilateral tibia fx, radius fx CT CT
No
No Radius fx, spleen laceration Yes, graft Rib fx, pulmonary contusion, pneumothorax, hip dislocation, liver and spleen laceration, kidney contusion CT No Rib fx, spine fx, scalp laceration CT Yes, graft Humerus fx, pelvic fx, maxilla and orbit fx, liver contusion CT, aortogram Yes, graft Rib fx, bilateral radius fx
Complications None
Renal failure, paraplegia, sepsis, pneumonia None Pulmonary embolus
None Recurrent laryngeal nerve injury None
BCA indicates bicycle accident; MVC motor vehicle crash; ATV, all-terrain vehicle crash; CT computed tomography; TEE, transesophageal echocardiography; fx, fracture.
Traumatic aortic injuries in the pediatric population Table 3
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Traumatic abdominal aortic injuries
Patient Age (y) Sex Mechanism Restraint Diagnosis Repair of injury 8 9
16 16
M M
MVC MVC
Yes Yes
CT CT
10 11
7 7
F M
MVC MVC
Yes Yes
CT CT
No No
Associated injuries
Small intestine perforation, colon serosa injury Pneumothorax, spine fx, small intestine and colon perforation Yes, primary Spine fx, small intestine perforation No Pulmonary contusion, spine fx, small intestine and colon perforation
Complications None None None None
At the time of presentation to our institution, the patients' mean heart rate was 109.1 ± 5.2 beats per minute (range, 77136 beats per minute). Their mean arterial blood pressure was 86.3 ± 3.3 mm Hg, with the systolic blood pressure ranging from 101 to 157 mm Hg (Table 1). All of the children presented with a normal hemoglobin measurement (Table 1). Computed tomography (CT) of the chest was the diagnostic modality for all 7 thoracic aortic injuries. Two patients had confirmatory angiograms, and one patient had confirmation of injury using transesophageal echocardiography. The injuries to the thoracic aorta included 4
transections of the proximal descending thoracic aorta, 2 intimal flap tears, and 1 aortic pseudoaneurysm. Three of the 7 children with thoracic aortic injuries were managed nonoperatively with blood pressure control alone, including the children with the intimal flap tears and the pseudoaneurysm. The other 4 patients underwent operative repair using interposition grafts. Bypass or shunting was used in 2, with the others undergoing a clamp and sew technique. Abdominal aortic injuries were diagnosed by CT of the abdomen (Figs. 1 and 2), and no further diagnostic testing was performed in those children. Three of the 4 abdominal aortic injuries were consistent with an intimal flap tear, whereas the other injury was an aortic dissection at the infrarenal artery. Only one child with an abdominal aortic injury underwent operative repair owing to abnormal ankle brachial index measurement and diminished distal pulses. This child had an intimal tear of the infrarenal aorta and underwent primary repair of the aortic intima and placement of an iliac vein patch. The other children with abdominal aortic injuries were hemodynamically stable with normal distal pulses and were managed nonoperatively. The average time from presentation with an aortic injury to the initiation of an operative procedure was 91.4 ± 28.9 minutes (range, 15-305 minutes).
Fig. 1 Computed tomographic scan demonstrating a traumatic dissection of the abdominal aorta (white arrow) originating at the level of the right renal artery. This child was managed with nonoperative measures including blood pressure control and close follow-up.
Fig. 2 Computed tomographic scan demonstrating an intimal tear in the infrarenal aorta (solid white arrow) with pneumoperitoneum (dashed white arrow). This child underwent laparotomy for repair of a hollow viscus and required aortic repair because of diminished peripheral pulses and an abnormal ankle brachial index.
mechanisms of injury were one fall, one bicycle vs automobile crash, and one all-terrain vehicle crash. Seven children had injuries to the thoracic aorta (mean Injury Severity Score [ISS], 24.3; range, 17-34), and 4 had abdominal aortic injuries (mean ISS, 21.2; range, 16-26). All 4 of the children with abdominal aortic injuries were restrained passengers involved in motor vehicle crashes. None of the 4 children who sustained injuries to the thoracic aorta from motor vehicle crashes were restrained.
2.2. Diagnosis and treatment
1080
2.3. Associated injuries Associated injuries were common (Tables 2 and 3). All 4 of the children with abdominal aortic injury had small bowel injuries, 3 had large bowel injuries, 3 had spine fractures, and 2 had chest trauma. There were no solid organ injuries or long bone fractures in this group. Four of the 7 children with thoracic aortic injuries had associated solid organ injuries, including 3 children with hepatic injuries, 2 with splenic lacerations, and 2 with renal contusions. The children with thoracic aortic injuries also tended to have multiple broken bones, with all 7 having some type of fracture or dislocation injury. Three of the 11 children had an abnormal Glasgow Coma Score (GCS), but none of them had abnormalities by head CT.
2.4. Complications and outcomes There were no complications in the 4 children with abdominal aortic injuries. The 3 children with thoracic aortic injuries who were managed nonoperatively also developed no short-term complications. In those children with thoracic aortic injuries that were managed with aortic repair, one child developed paraplegia, pneumonia, sepsis, and renal failure requiring dialysis. Two other patients who underwent operation developed complications. One child sustained a recurrent laryngeal nerve injury, and another developed a pulmonary embolus. The median length of stay in the ICU was 4 days (range, 1-48 days). The median length of total hospital stay was 8 days (range, 2-48 days). All of the children survived their aortic injury. One child was discharged to a rehabilitation facility, and the other 10 were discharged home. The median length of follow-up is 16 months (range, 9118 months), with no adverse long-term sequelae noted. Of the 6 children managed nonoperatively, all have done well. Three of these children were discharged from clinic. The other 3 have been followed with serial CT imaging, and all have stable aortic dissections.
3. Discussion Trauma remains the leading cause of death in children, but traumatic vascular injuries and injuries to the aorta in particular are rarely encountered in the pediatric trauma population [6]. A recent study by Heckman et al using the National Trauma Data Base reported an incidence of blunt thoracic aortic injury in children of 0.1% [7]. Blunt injury to the abdominal aorta in the pediatric population is even more unusual and is marked by only scattered case reports in the literature. This report examines our experience with blunt aortic injuries in the pediatric population and represents a large series of patients presenting with an uncommon problem.
S.A. Anderson et al. There were no deaths in our series, despite previous reports of extremely low survival rates for children with blunt aortic injury. In fact, one report had only one survivor in 13 pediatric patients with aortic injuries [6]; however, the data previously reported from the National Trauma Data Base suggest a much better survival [7]. Some investigators believe that the primary prognostic determinant of morbidity and mortality for children with truncal vascular injuries is their hemodynamic status upon admission and that a systolic blood pressure less than 90 mm Hg is a strong indicator of poor outcome [6,8]. However, hemodynamic status was not predictive of outcome in our series. In fact, two thirds of the children were hemodynamically unstable with tachycardia (heart rate N100 beats per minute) upon presentation, although none of them had a systolic blood pressure less than 100 mm Hg. The survival in this study may be skewed, however, because there is the possibility that we did not capture all of the children with blunt aortic injures. For example, children who died before or upon arrival at our institution, who actually had aortic injuries, may have gone undiagnosed or may not have been entered into the databases and would be missed by our searching by diagnosis codes. In addition, survival differences may be attributable to the evolution of more sensitive diagnostic modalities, detecting injuries that may be hemodynamically insignificant and have gone without notice in the past. The significant incidence of associated injuries in our series highlights the fact that aortic injuries in children are the result of the application of a tremendous force. All of the children with blunt thoracic aortic injuries sustained fractures, and solid organ injuries were also common. Interestingly, head injuries were not commonly seen, although head injury remains the primary cause of traumatic death in children [9]. Spine fractures (Chance fractures) were noted in 3 of the children with abdominal aortic injury. This finding is not unexpected because all 4 of these children were restrained with a seat belt. The association of Chance fractures and seat belt use is well documented in the literature. In addition, the triad of a seat belt sign, abdominal viscus injury, and Chance fracture is well documented [10]. The interesting finding in this series is the association of a perforated viscus with an abdominal aortic injury. All of the children with abdominal aortic injuries sustained a hollow viscus injury that required surgical intervention. Initial CT scans demonstrated the aortic injury in all 4 children, but did not immediately identify the perforated viscus in 3 of them. These 3 children developed deterioration in their abdominal examinations, prompting further radiographic investigation or immediate surgical exploration to repair their intestinal injuries. There is no consensus in the literature on the optimal management of blunt aortic injuries. Most authors report repair of thoracic aortic injuries with either primary repair or a graft, using bypass, shunting, or clamp and sew techniques [3,5,6]. There are reports of nonoperative management of these injuries in children using blood pressure control and
Traumatic aortic injuries in the pediatric population close observation [5]. This option is usually reported in those patients who are felt to be too ill to withstand a major operation. Some authors feel that thoracic aortic injuries in children may be approached as they would be in adults [5]. In our series, 3 of the patients with thoracic aortic injuries were managed nonoperatively because of their hemodynamic stability. There are also recent reports in the literature using endovascular stents for the treatment of aortic injuries in the pediatric population [4,5,11]. Ricketts and others reported good results in 2 patients, but had a relatively short follow-up of 1 to 2 years [11]. The difficulties associated with small vessel size and lack of long-term outcomes data even in the adult population currently temper the enthusiasm for this treatment option in young children; but it may be amenable to use in older, larger patients. In our report, only one child underwent surgical intervention for abdominal aortic injury. The decision to operate was based upon finding diminished peripheral pulses and abnormal ankle brachial indices. The other 3 children with abdominal aortic injuries were managed without operation and have done well, although the aorta remains abnormal by follow-up imaging studies. There are reports in the literature of long-term rupture of the aorta, prompting the need for long-term follow-up of these children.
4. Conclusion Blunt aortic injury in the pediatric trauma patient is rare and primarily occurs in the multiply injured patient. In our
1081 series, abdominal aortic injuries were commonly associated with hollow viscus injury, prompting a need for a high index of suspicion when managing these severely injured children.
References [1] Moront ML, Williams JA, Eichelberger MR, et al. The injured child: an approach to care. Pediatr Clin North Am 1994;41:1201-26. [2] EAST http://www.east.org/tpg.html. [3] Takach TJ, Anstadt MP, Moore HV. Pediatric aortic disruption. Tex Heart Inst J 2005;32:16-20. [4] Aidinian G, Kamaze M, Russo EP, et al. Endograft repair of traumatic aortic transection in a 10-year–old: a case report. Vasc Endovascular Surg 2006;40:239-42. [5] Karmy-Jones R, Hoffer E, Meissner M, et al. Management of traumatic rupture of the thoracic aorta in pediatric patients. Ann Thorac Surg 2003;75:1513-7. [6] Cox CS, Black CT, Duke JH, et al. Operative treatment of truncal vascular injuries in children and adolescents. J Pediatr Surg 1998;33: 462-7. [7] Heckman SR, Trooskin SZ, Burd RS. Risk factors for blunt thoracic aortic injury in children. J Pediatr Surg 2005;40:98-102. [8] Holmes JF, Sokolove PE, Brandt WE, et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002;39:492-8. [9] National Trauma Database http://www.ntdb.org. [10] Choit RL, Tredwell SJ, Leblanc JG, et al. Abdominal aortic injuries associated with chance fractures in pediatric patients. J Pediatr Surg 2006;4:1184-90. [11] Milas ZL, Milner R, Chaikoff E, et al. Endograft stenting in the adolescent population for traumatic aortic injuries. J Pediatr Surg 2006; 4:E27-E30.
www.elsevier.com/locate/jpedsurg
Traumatic aortic injuries in the pediatric population Scott A. Anderson, Mathew Day, Mike K. Chen, Thomas Huber, Lawrence L. Lottenberg, David W. Kays, Elizabeth A. Beierle⁎ Department of Surgery, PO Box 100286, JHMHSC, Gainesville, FL 32610-0286, USA Received 30 January 2008; accepted 9 February 2008
Key words: Pediatric; Trauma; Abdominal; Thoracic; Aorta; Vascular; Injury
Abstract Background/Purpose: Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period. Methods: After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded. Results: There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home. Conclusions: Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained. © 2008 Elsevier Inc. All rights reserved.
Traumatic injury remains the most common cause of death and disability in the pediatric population. It is estimated that 20,000 children die each year from traumatic injuries [1]. Despite increases in the incidence of penetrating trauma, blunt trauma remains the most common mechanism of injury in children, including motor vehicle crashes, falls, and vehicle vs pedestrian crashes. Presented at the 59th Annual Meeting of the Section on Surgery, American Academy of Pediatrics, San Francisco, CA, October 25-27, 2007. ⁎ Corresponding author. Tel.: +1 352 392 3718; fax: +1 352 392 9081. E-mail address: [email protected] (E.A. Beierle). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.02.030
Traumatic aortic injuries result in significant morbidity and mortality. The management of aortic injuries in adult trauma patients has been well established, based upon both military and civilian experiences. In fact, the Eastern Association for the Surgery of Trauma has published best practice guidelines for the diagnosis and treatment of traumatic thoracic aortic injuries in adults that are available on the Internet [2]. Vascular injuries in children are much less common and are primarily iatrogenic injuries sustained during catheterization procedures or traumatic injuries to the vasculature of the extremities. Most reports of aortic injuries in children are limited to case reports or small series [3-5],
1078
S.A. Anderson et al.
Table 1 Hemodynamics, hemoglobin, and GCS at presentation Patient
Systolic BP (mm Hg)
Mean arterial pressure
Heart rate (beats/min)
Hgb (g/dL)
GCS
1 2 3 4 5 6 7 8 9 10 11
115 147 101 124 137 110 157 134 128 130 110
83.7 106.3 71 86 82.3 78.7 94 94 92 92 69.3
116 136 96 77 95 130 119 96 114 116 105
12.1 12 14 12 11.6 15.2 13 15 14.1 12.6 11
15 15 15 12 15 12 15 13 15 15 15
Hgb indicates hemoglobin.
and there is an even greater paucity of data available pertaining to the injury of the abdominal aorta in children. The purpose of this report is to investigate the patient demographics, mechanisms of injury, associated injuries, treatment of aortic injuries, and outcome of pediatric patients with these injuries cared for at a single institution.
1. Methods Approval for this study was obtained from the Institutional Review Board at the University of Florida. Both the hospital and pediatric surgery databases were queried for all pediatric patients seen at our institution who were younger
Table 2
than 20 years and had sustained traumatic injury to either the thoracic or abdominal aorta, including The International Classification of Diseases, Ninth Revision, Clinical Modification (Sixth Edition), codes 901.0 to 901.0, over a 10-year period from January 1996 to July 2006. A retrospective review of the hospital and clinic charts of these children was performed. Children with injuries limited to a major branch of the aorta, such as the carotid, mesenteric, renal, or iliac arteries, were excluded from review. All children were evaluated by the Pediatric Surgery or Trauma Surgery services at the University of Florida. Data regarding patient demographics, mechanism of injury, hemodynamic status at presentation, diagnostic modalities, specific vascular diagnostic modalities, associated injuries, therapy, complications, and outcomes were gathered. Where appropriate, data are reported as mean ± standard error of the mean.
2. Results The results are presented in tabular form in Tables 1-3.
2.1. Patient demographics and mechanism of injury There were 11 patients who met the aforementioned criteria. The mean age of the patients was 14.3 ± 1.2 years (range, 7-19 years). The youngest patient was 7 years, and only 3 of the patients were older than 16 years. Most of the children were male (n = 8, 72%), and most were injured as occupants of a motor vehicle crash (n = 8, 72%). The other
Traumatic thoracic aortic injuries
Patient Age (y) Sex Mechanism of Injury
Restraint Diagnosis
1
13
M
BCA, no helmet –
2
16
M
MVC
No
3 4
13 19
M F
ATV, no helmet MVC
– No
5 6
15 17
M F
MVC MVC
No No
7
18
M
Fall
–
CT, TEE
Repair
Associated injuries
Rib fx, pulmonary contusion, pneumothorax, femur fx, acromion fx, liver laceration, kidney contusion CT, aortogram Yes, graft Femur and bilateral tibia fx, radius fx CT CT
No
No Radius fx, spleen laceration Yes, graft Rib fx, pulmonary contusion, pneumothorax, hip dislocation, liver and spleen laceration, kidney contusion CT No Rib fx, spine fx, scalp laceration CT Yes, graft Humerus fx, pelvic fx, maxilla and orbit fx, liver contusion CT, aortogram Yes, graft Rib fx, bilateral radius fx
Complications None
Renal failure, paraplegia, sepsis, pneumonia None Pulmonary embolus
None Recurrent laryngeal nerve injury None
BCA indicates bicycle accident; MVC motor vehicle crash; ATV, all-terrain vehicle crash; CT computed tomography; TEE, transesophageal echocardiography; fx, fracture.
Traumatic aortic injuries in the pediatric population Table 3
1079
Traumatic abdominal aortic injuries
Patient Age (y) Sex Mechanism Restraint Diagnosis Repair of injury 8 9
16 16
M M
MVC MVC
Yes Yes
CT CT
10 11
7 7
F M
MVC MVC
Yes Yes
CT CT
No No
Associated injuries
Small intestine perforation, colon serosa injury Pneumothorax, spine fx, small intestine and colon perforation Yes, primary Spine fx, small intestine perforation No Pulmonary contusion, spine fx, small intestine and colon perforation
Complications None None None None
At the time of presentation to our institution, the patients' mean heart rate was 109.1 ± 5.2 beats per minute (range, 77136 beats per minute). Their mean arterial blood pressure was 86.3 ± 3.3 mm Hg, with the systolic blood pressure ranging from 101 to 157 mm Hg (Table 1). All of the children presented with a normal hemoglobin measurement (Table 1). Computed tomography (CT) of the chest was the diagnostic modality for all 7 thoracic aortic injuries. Two patients had confirmatory angiograms, and one patient had confirmation of injury using transesophageal echocardiography. The injuries to the thoracic aorta included 4
transections of the proximal descending thoracic aorta, 2 intimal flap tears, and 1 aortic pseudoaneurysm. Three of the 7 children with thoracic aortic injuries were managed nonoperatively with blood pressure control alone, including the children with the intimal flap tears and the pseudoaneurysm. The other 4 patients underwent operative repair using interposition grafts. Bypass or shunting was used in 2, with the others undergoing a clamp and sew technique. Abdominal aortic injuries were diagnosed by CT of the abdomen (Figs. 1 and 2), and no further diagnostic testing was performed in those children. Three of the 4 abdominal aortic injuries were consistent with an intimal flap tear, whereas the other injury was an aortic dissection at the infrarenal artery. Only one child with an abdominal aortic injury underwent operative repair owing to abnormal ankle brachial index measurement and diminished distal pulses. This child had an intimal tear of the infrarenal aorta and underwent primary repair of the aortic intima and placement of an iliac vein patch. The other children with abdominal aortic injuries were hemodynamically stable with normal distal pulses and were managed nonoperatively. The average time from presentation with an aortic injury to the initiation of an operative procedure was 91.4 ± 28.9 minutes (range, 15-305 minutes).
Fig. 1 Computed tomographic scan demonstrating a traumatic dissection of the abdominal aorta (white arrow) originating at the level of the right renal artery. This child was managed with nonoperative measures including blood pressure control and close follow-up.
Fig. 2 Computed tomographic scan demonstrating an intimal tear in the infrarenal aorta (solid white arrow) with pneumoperitoneum (dashed white arrow). This child underwent laparotomy for repair of a hollow viscus and required aortic repair because of diminished peripheral pulses and an abnormal ankle brachial index.
mechanisms of injury were one fall, one bicycle vs automobile crash, and one all-terrain vehicle crash. Seven children had injuries to the thoracic aorta (mean Injury Severity Score [ISS], 24.3; range, 17-34), and 4 had abdominal aortic injuries (mean ISS, 21.2; range, 16-26). All 4 of the children with abdominal aortic injuries were restrained passengers involved in motor vehicle crashes. None of the 4 children who sustained injuries to the thoracic aorta from motor vehicle crashes were restrained.
2.2. Diagnosis and treatment
1080
2.3. Associated injuries Associated injuries were common (Tables 2 and 3). All 4 of the children with abdominal aortic injury had small bowel injuries, 3 had large bowel injuries, 3 had spine fractures, and 2 had chest trauma. There were no solid organ injuries or long bone fractures in this group. Four of the 7 children with thoracic aortic injuries had associated solid organ injuries, including 3 children with hepatic injuries, 2 with splenic lacerations, and 2 with renal contusions. The children with thoracic aortic injuries also tended to have multiple broken bones, with all 7 having some type of fracture or dislocation injury. Three of the 11 children had an abnormal Glasgow Coma Score (GCS), but none of them had abnormalities by head CT.
2.4. Complications and outcomes There were no complications in the 4 children with abdominal aortic injuries. The 3 children with thoracic aortic injuries who were managed nonoperatively also developed no short-term complications. In those children with thoracic aortic injuries that were managed with aortic repair, one child developed paraplegia, pneumonia, sepsis, and renal failure requiring dialysis. Two other patients who underwent operation developed complications. One child sustained a recurrent laryngeal nerve injury, and another developed a pulmonary embolus. The median length of stay in the ICU was 4 days (range, 1-48 days). The median length of total hospital stay was 8 days (range, 2-48 days). All of the children survived their aortic injury. One child was discharged to a rehabilitation facility, and the other 10 were discharged home. The median length of follow-up is 16 months (range, 9118 months), with no adverse long-term sequelae noted. Of the 6 children managed nonoperatively, all have done well. Three of these children were discharged from clinic. The other 3 have been followed with serial CT imaging, and all have stable aortic dissections.
3. Discussion Trauma remains the leading cause of death in children, but traumatic vascular injuries and injuries to the aorta in particular are rarely encountered in the pediatric trauma population [6]. A recent study by Heckman et al using the National Trauma Data Base reported an incidence of blunt thoracic aortic injury in children of 0.1% [7]. Blunt injury to the abdominal aorta in the pediatric population is even more unusual and is marked by only scattered case reports in the literature. This report examines our experience with blunt aortic injuries in the pediatric population and represents a large series of patients presenting with an uncommon problem.
S.A. Anderson et al. There were no deaths in our series, despite previous reports of extremely low survival rates for children with blunt aortic injury. In fact, one report had only one survivor in 13 pediatric patients with aortic injuries [6]; however, the data previously reported from the National Trauma Data Base suggest a much better survival [7]. Some investigators believe that the primary prognostic determinant of morbidity and mortality for children with truncal vascular injuries is their hemodynamic status upon admission and that a systolic blood pressure less than 90 mm Hg is a strong indicator of poor outcome [6,8]. However, hemodynamic status was not predictive of outcome in our series. In fact, two thirds of the children were hemodynamically unstable with tachycardia (heart rate N100 beats per minute) upon presentation, although none of them had a systolic blood pressure less than 100 mm Hg. The survival in this study may be skewed, however, because there is the possibility that we did not capture all of the children with blunt aortic injures. For example, children who died before or upon arrival at our institution, who actually had aortic injuries, may have gone undiagnosed or may not have been entered into the databases and would be missed by our searching by diagnosis codes. In addition, survival differences may be attributable to the evolution of more sensitive diagnostic modalities, detecting injuries that may be hemodynamically insignificant and have gone without notice in the past. The significant incidence of associated injuries in our series highlights the fact that aortic injuries in children are the result of the application of a tremendous force. All of the children with blunt thoracic aortic injuries sustained fractures, and solid organ injuries were also common. Interestingly, head injuries were not commonly seen, although head injury remains the primary cause of traumatic death in children [9]. Spine fractures (Chance fractures) were noted in 3 of the children with abdominal aortic injury. This finding is not unexpected because all 4 of these children were restrained with a seat belt. The association of Chance fractures and seat belt use is well documented in the literature. In addition, the triad of a seat belt sign, abdominal viscus injury, and Chance fracture is well documented [10]. The interesting finding in this series is the association of a perforated viscus with an abdominal aortic injury. All of the children with abdominal aortic injuries sustained a hollow viscus injury that required surgical intervention. Initial CT scans demonstrated the aortic injury in all 4 children, but did not immediately identify the perforated viscus in 3 of them. These 3 children developed deterioration in their abdominal examinations, prompting further radiographic investigation or immediate surgical exploration to repair their intestinal injuries. There is no consensus in the literature on the optimal management of blunt aortic injuries. Most authors report repair of thoracic aortic injuries with either primary repair or a graft, using bypass, shunting, or clamp and sew techniques [3,5,6]. There are reports of nonoperative management of these injuries in children using blood pressure control and
Traumatic aortic injuries in the pediatric population close observation [5]. This option is usually reported in those patients who are felt to be too ill to withstand a major operation. Some authors feel that thoracic aortic injuries in children may be approached as they would be in adults [5]. In our series, 3 of the patients with thoracic aortic injuries were managed nonoperatively because of their hemodynamic stability. There are also recent reports in the literature using endovascular stents for the treatment of aortic injuries in the pediatric population [4,5,11]. Ricketts and others reported good results in 2 patients, but had a relatively short follow-up of 1 to 2 years [11]. The difficulties associated with small vessel size and lack of long-term outcomes data even in the adult population currently temper the enthusiasm for this treatment option in young children; but it may be amenable to use in older, larger patients. In our report, only one child underwent surgical intervention for abdominal aortic injury. The decision to operate was based upon finding diminished peripheral pulses and abnormal ankle brachial indices. The other 3 children with abdominal aortic injuries were managed without operation and have done well, although the aorta remains abnormal by follow-up imaging studies. There are reports in the literature of long-term rupture of the aorta, prompting the need for long-term follow-up of these children.
4. Conclusion Blunt aortic injury in the pediatric trauma patient is rare and primarily occurs in the multiply injured patient. In our
1081 series, abdominal aortic injuries were commonly associated with hollow viscus injury, prompting a need for a high index of suspicion when managing these severely injured children.
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