22 years old gentleman been through RTA and was wearing seat belt
Presented with ribs fracture femur (shaft fracture) stable and right side chest haemothorax needed chest tube with minimal drainage
He is hemodynamically stable and Hb is 11 g/dl
What would be your approach for assessment and stabilization
What would be the first line of investigation
CTA showing grade 2-3 Vancouver aortic injury distal to left SCA
What would be your initial management plan
After 48 hrs started to be tachycardic and Hb dropped by 3 grams
Repeated CTA showed further left side hemothorax
What would be your management and intervention plan please
ABCD protocol ensuring hemodynamic stability
Patient need icu admission and close vitals monitoring including blood pressure and follow up cbc
fractured femur needs to be reduced with assessment of distal perfusion including palpation of tibial pulses and duplex us
Investigation of choice of suspected aortic injury is CTA
Vancouver grade 2-3 is managed with close observation and monitoring of chest tube , cbc , blood pressure monitoring and control with adequate analgesia and follow up CTA if indicated
presence of further hb drop and increased hemothorax necessitates further work up including CT aortogram if hemodynamicsloy stable
patients needs urgent blood transfusion and permissible hypotension while preparing the patient for operation with close vitals and lab monitoring
traumatic aortic dissection can be managed with endovascular route – placement of covered stent with urgent planing for appropriate landing zone and the need for carotid subclavian bypass if needed.
1
first start with ATLS approach:
primary survey: airway ,breathing ,circulation, disability, exposure
1st line investigation:
cbc, VBG, electrolytes, coagulation profile
CXR, pelvic x ray, Fast scan and CTA
initial management include:
ICU admission
blood pressure control
vital data monitor
fluid resuscitation
HB level follow up and cross matching
good anelgesia
if still dteriorating
Chest tube insertion
blood transfusion
arrange for EVAR
open surgery by anterolateral thoracotomy
Initial Presentation & Stabilization:
Primary Survey (ABCs)
First Line Investigations:
Initial Management Plan for Grade 2-3 Aortic Injury:
Medical management:
Deterioration at 48 hours: The patient shows concerning signs:
Management Plan for Deterioration:
Immediate Steps:
Intervention Options:
Monitoring:
ICU admission if not already there
A1 i will manage acoording ATLs protocol
maintain aiway and breathing by o2 mask
insert 2 large bore cannula and withdraw blood test (cbc-kidney function-coagulation profile -abg)and send for blood group matching
start resusitation with hartman solution 1L over 30 min
and start blood transfusion if patient vitals not improve
check pupil -GCS and exposure of patient
A2 fast and CTA
A3 if patient vitally stable i will start with conservative treatment and regular monitor of patiwnt vitals
give b blocker and pain managment
and permessive hypotension
A4 i will monitor patient breathing amd insert chest tube and monitor its drain
consider endovascular option 1st
and open surgery as a 2nd option
1-abode approach
2- cbc, bleeding, cross and match , bit k+ fast scan , ct chest with contrast
3- tight control of blood pressure close follow up of clinical signs and vitals of pt , repeat cbc
4-arrange for tevar if possible if not go for urgent thoractomy after stabilizing and bl reservation (1:1:1)
Q1…
My approachATLS protocol (A,B,C,D,E)
-Airway: enusure it is patent and cervical spine
-Breathing: adequate oxygenation with oxygen mask
-Circulation: vitals measure like capillary refilling, pulse oximetar
Control of bleeding, BP, urine output
-Disability: GCS, neurological examination, pupil reaction
-Exposure of body from head to toe
Then proceed to FAST scan, Plain chest x-ray, ABG, lab tests, blood group cross matching, CT chest, abdomen and pelvis.
…..
Q2
Fast
CTangio
Labs, cbc, cross match, RBG, electrolytes
….
Q3
I will mange pt conservatively
BP between 70 to 90
And add beta blocker
Inform my vascular consultant
I for ITU registrar
Inform anastasia if pt condition deteriorate any time for
….
Q4
Consider blood transfusion
Close monitoring pt condition
Inform my consultant
Endo is good way for management
But still we have open surgery
Q1…
My approachATLS protocol (A,B,C,D,E)
-Airway: enusure it is patent and cervical spine
-Breathing: adequate oxygenation with oxygen mask
-Circulation: vitals measure like capillary refilling, pulse oximetar
Control of bleeding, BP, urine output
-Disability: GCS, neurological examination, pupil reaction
-Exposure of body from head to toe
Then proceed to FAST scan, Plain chest x-ray, ABG, lab tests, blood group cross matching, CT chest, abdomen and pelvis.
…..
Q2
Fast
CTangio
Labs, cbc, cross match, RBG, electrolytes
….
Q3
I will mange pt conservatively
BP between 70 to 90
And add beta blocker
Inform my vascular consultant
I for ITU registrar
Inform anastasia if pt condition deteriorate any time for
….
Q4
Consider blood transfusion
Close monitoring pt condition
Inform my consultant
Endo is good way for management
But still we have open surgery
Very good answer
>> First full evaluation and assessment is a must as polytraumatic patient so full survey I would do after starting with the ABCDE approach to maintain and stablize the patient and his vitals especially resuscitation with permissive bp with systolic bp not exceeding 90 mmhg
>> my intial investigation in the full assessment is FAST scan followed by CT of abdomine and pelvis
>> hence the patient is hemodynamically stable, I would go with a conservative management approach, in the form of:
administration of b-blockers to strict blood pressure and heart rate.
pain control with analgesics and oxygen therapy.
and of course close monitoring of vital data.
>> After 48 hours, the patient shows a hemodynamic instability. A CTA reveals a new left-sided hemothorax, indicating worsening of the condition an urgent intervention ASAP must be done. with TEVAR as the first-line option, while keeping surgical repair as a secondary alternative if required.
Good systematic approach and management
Q1
As pt is stable move from ABCDE for investigation Fast, x ray
Ct cheast
Ct aortography
Blood banking
Admit at icu with close observation
Control Bp<90 with b blockers
Arrange for recent cta post 48 hrs
———-
Q2
Recent ct chest
Recent cta
Calculation of blood at chest tube / hr
————
Q3
Chest tube insertion with calcultion of loss
Compensate hb drop
Continue conservative with very close follow up for ht rate, BP , blood collected, hb drop, RR
Arrange for possibility of TEVAR or open surgery
—————
Q4
My be endovascular TEVAR
If failed open thoracotomy
Reasonable approach and management plan
Q1: following ATLS protocol with primary survey ABCDE and arranging the injuries priorities
Q2: once ribs fractures CTA to exclude suspected blunt aortic trauma
Q3: delayed intervention and close monitoring and permissive hypotension below 100 mmhg
Q4:prepare for intervention urgent TEVAR
Good answer
approach for assessment and stabilization :
ABCDE approach as first assessment to a Emergency patient < ATLS should be applied also as the patiet is a trauma patient.
first line of investigations :
laboratory investigations , compleate blood count.
Imaging , chest xray , FAST scan .
or pan plain CT.
initial managment plan:
secure air way and use adjacents if needed , 2 wide bore canula for fluid resuscitation if needed. full exposure .compleate primary survey .
admit the patient for close monitoring , keeep permesive hypotension .
plan for endovascular stentgrafting.
managment plane ater the patient condition deteriorated : open surgery repair may be cosidered.
I believe the plain CT scan would not give enough information about any vascular injury, evidence would support having CTA
Open surgery could be always an option , but looking at the patient general condition and assessment of the patient fitness would suggest Endovascular intervention as first line of intervention
1-Following ATLS protocol the primary survey nearly completed, chest tube for rt side heamothorax, stabilization of the peripheral fracture, cbc and abo match withdrawn,
Keep the patient on permissive hypotension side resuscitation, recheck the cxr and fast scan if done, abd exam, assure pelvic stability
Check for signs of vascular injury :prescence and equality of pulses in all 4 limbs both radial and both femoral pulses, then vascular exam of fractured limb distal to the fracture
2-So in 2ry survey according to mech of injury a I will order a ct aortography from major branches of the arch to the iliacs level to exclude major vessels injury or abd organs injury
or to the popliteal A level if there are signs of vascular injury with the fracture
3- the aortic injury in the cta is managed nonsurgical by icu admission and close observation, vital signs monitoring, serial cbc, pain control, Beta blockers may be of value
4- continue resuscitation of the patient according to ATLS , blood components transfusion, O2 mask, and a chest tube for the lt sided heamothorax,
If accepted amount is drained and patient is stabilized we will continue conservative ttt of aortic injury as seen in the 2nd video is still vancouver 2-3 and plan TEVAR after 2 weeks of trauma and plan lt SCA revasc if needed
If the chest tube drains non stopable significant amount urgent TEVAR may be considered.
Drop of Hb and clinical changes indicate the patient is indicated for intervention with TEVAR
Good answer
A1: I will start assessing the patient according to ATLS protocol with primary and secondary surveys and definitive care will be Icu admission – permissive hypotension -CTA- prioritizing any other life-threatening injury
A2: CTA to exclude any blunt thoracic aortic injury in addition to HB for follow-up with RFTs and INR
A3: permissive hypotension-BB- strict follow-up
A4: rapid resuscitation of the patient with correction of the HB drop and prepare the patient for the intervention
A5: Transfer the patient to the Angio suite for emergency EVAR
I believe you mean TEVAR
Good answer
Q:1
My approach according to ATLS protocol (A,B,C,D,E)
-Airway: enusure it is patent
-Breathing: adequate oxygenation with oxygen mask
-Circulation: Control of bleeding, maintain blood presure with SBP not more than 90mmHg
-Disability: GCS, neurological examination
-Exposure of body from head to toe
Then proceed to FAST scan, Assess pulses, Plain chest x-ray, ABG, lab tests, blood group cross matching, CT chest, abdomen and pelvis.
Urinary catheter insertion for measuring urine output.
Q:2
CT chest to assess the extent of hemothorax, evaluation of thoracic aorta.
CT aniography of abdominal aorta and both lower limb arteries if femoral pulse is absent.
Q:3
Vascular consulation for intervention preparation:
ensure adequate blood transfusion, minimise bleeding and control of BP not more than SBP of 90 mmHg.
Endovascular Aortic repair should be considered or open surgery in case of failure of endovascular intervention.
Q:4: Management of tachycardia and Hb drop:
CT scan should be repeated, measurement of chest drain, blood transfusion and close monitoring for possibility of intervention.
Q:5: LT sided Hemothorax
Consider stabalization of blood pressure, control of bleeding either by radiological intervention for embolization of bleeding vessel or consider open surgery in case of profuse bleeding.
Antibiotics should be given, IV fluids and strong analgesics.
Good answer
Initially if the patient stable , we may consider delay TEVAR as per growing evidence (systematic review and meta-analysis) showing better outcome
But overall good approach and assessment
What would be your approach for assessment and stabilization
ABC
Avoid over resucitation depends on permeaive hypotensive resucitation
Assessment of peripheral vasculature and Search for any hard signs for vascular injuries if no PT stable we go for CTA for assessment and management according to results
CTA showing grade 2-3 Vancouver aortic injury distal to left SCA
What would be your initial management plan
tight folw up and PT to be prepared for Tevar if deteriorations happened
After 48 hrs started to be tachycardic and Hb dropped by 3 grams Repeated CTA showed further left side hemothorax What would be your management and intervention plan please
Resucitation go for
Emergency Tevar s
Well done, good answer, approach and assessment
Start the ABCDE protocol for trauma patient
As the patient is hemodynamically stable so continue the 1ry survey woth FAST for abdominal injury and C spine xray regarding the mechanism of injury
Management plan for this patient with vancouver grade 2 is conservative with close follow up and permissive hypotension with b blockers or CCB and oxygenation and restricted fluid resuscitation
With the progress of the patient condition and the change in grade of aortic dissection to grade 3 with lt hemothorax and hg drop so definitive ttt with TEVAR after the ABCDE with fluid and blood transfusion along with lt chest tube insertion
Very good, consider early CTA and follow up CTA if patient is stable
q1: I will start patient evaluation and assessment using the ATLS approach i will start with ABCDE PROTOCOL
airway: ensuring patent and secure airway is very crucial in patient management
breathing and circulatory evaluation are very important blood pressure should be kept within permissive hypotension protocol and systolic blood pressure should be between 70-9- MMHG
finally, patient exposure to find any hidden injury
q2: the first line of investigation is pelviabdominal US ( FAST SCAN)
then I will proceed with a full CT scan from head to pelvis
q3: as the patient is hemodynamically stable with no hemoglobin drop and the chest tube shows minimal drainage my initial management plan will be conservative treatment with strict control of blood pressure and heart rate with beta-blockers, administration of analgesics and O2 and follow-up of vital signs
q4: After 48 hours of conservative management, there starts to be HB drop and hemodynamic instability and CTA showed left side haemothorax that wasn’t present before. so the patient now becomes Vancouver grade 3 to 4 and intervention now becomes a must .I think repair with TEVAR as a first option for intervention would be a reasonable approach and of course surgery is an option but I will begin with TEVAR at first
Very good methodical approach, well done
Q1::Initial Assessment and Stabilization:
Primary Survey:
Focus on airway, breathing, circulation, and disability (ABCDE).
Ensure patent airway, adequate ventilation (possibly with supplemental oxygen), and control bleeding (chest tube drainage).
Assess neurological status and other injuries.
Secondary Survey: Perform a head-to-toe examination, including a detailed assessment of the chest and abdomen. Order relevant investigations like chest X-ray, CT scan of the chest and abdomen, and blood tests.
Q2:First-Line Investigation:
Chest X-ray: To assess lung fields, presence of pneumothorax or hemothorax, and rib fractures. CT scan of the chest: To evaluate the extent of lung injury, presence of mediastinal hematoma or aortic injury.
Q3:Management of Aortic Injury:
Initial Management: The patient is likely to be transferred to a center with vascular surgery expertise for definitive management. In the interim, aggressive blood pressure control is crucial to minimize further bleeding. Endovascular Repair: If feasible, thoracic endovascular aortic repair may be considered to repair the aortic injury. Open Surgical Repair: If endovascular repair is not possible or the injury is complex, open surgical repair may be necessary.
Monitoring and Management of Hemothorax:
Chest Tube Drainage: Continue chest tube drainage to evacuate blood and fluid from the pleural space. Monitor drainage output closely. Blood Transfusion: If the patient becomes hemodynamically unstable or the hemoglobin level drops significantly, blood transfusion may be required. Repeat Imaging: Consider repeat chest X-ray or CT scan to assess the effectiveness of chest tube drainage and identify any residual hemothorax.
Management of Tachycardia and Hemoglobin Drop:
Repeat CT Scan: To evaluate for further bleeding or new injury. Angiography: To assess for active bleeding from the aortic injury site or other sources. Interventional Radiology: If a bleeding source is identified, interventional radiology procedures like embolization may be considered to control bleeding. Surgical Exploration: If the bleeding source cannot be controlled with conservative measures or interventional radiology, surgical exploration may be necessary.
Additional Considerations:
Pain Management: Adequate pain control is essential to facilitate breathing and coughing, which can help prevent pulmonary complications. Antibiotic Prophylaxis: Consider prophylactic antibiotics to prevent infection, especially in the setting of open chest tube drainage or surgical intervention. Anticoagulation: Avoid anticoagulation due to the risk of bleeding, especially in the setting of aortic injury.
Close Monitoring: Close monitoring of vital signs, hemodynamic parameters, and drainage output is crucial.
Very good answer, consider delaying aortic intervention in the early stage if patient is stable and aortic injury is not significant (grade 2). Appropriate response to deterioration and methodical assessment and management. Well done