Blunt Aortic Injury with Concomitant Intra-abdominal Solid Organ Injury: Treatment Priorities Revisited Santaniello J, et al, The Journal of TRAUMA Injury, Infection, and Critical Care. 2002;53:442–445.

Background Blunt aortic injury (BAI): 90% mortality within first 24 hours Second leading cause of death in blunt trauma 15%~20% BAI patient with concomitant liver/spleen (L/S) injuries Cardiopulmonary bypass with heparinization for repair of BAI  L/S operation before aortic repair? Majority of blunt L/S injuries are now treated non-operatively in hemodynamically stable patients Evaluates safety of acute BAI repair using partial bypass with full heparinization in patients undergoing non-operative management (NOM) for low-grade blunt L/S injuries Conclusion: NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.

Patients and Methods BAI patient in Presley Regional Trauma Center over a 6-year period Study group: Patient with concomitant liver or spleen injury (Aorta L/S group) Control: patient with L/S injury but without BAI (L/S group)

Aortic Injury Management Patient screened by chest & abdominal CT  thoracic aortography Blood pressure and heart rate controlled pharmacologically to (SBP~100mmHg, HR < 100 bpm) BAI repaired by partial bypass with full heparinization

Solid Organ Injury Management Diagnosed by CT and graded by American Assoiciation for the Surgery of Trauma organ injury scale Aorta L/S vs. L/S Aorta L/S vs. Aorta

Results 84 patients with BAI 56 p’t without associated intra-abdominal injury 28 p’t with concomitant liver and/or spleen injury Aorta L/S group: 20 patients with solid organ injury (Table 1) L/S group: 894 patients with grade I/II hepatic or splenic injury Aorta L/S group vs. L/S group (Table 2) Aorta L/S group vs. Aorta group (Table 3) Complication rates (Table 4)

Results No difference in resource use (length of stay) or failure of non-operative solid organ injury management Similar overall complication rate

Discussion1 Past: positive peritoneal lavage  laparotomy  aortic repair Present: recent shift in management of blunt L/S injuries to non-operative management Aortic repair with involvement of systemic anticoagulation  increase risk of hemorrhage? Approaches to BAI with blunt L/S injury: 1. Delay repair of aorta until injured intra-abdominal organ has healed  longer hospital stay in increased costs 2. Perform laparotomy with removal or repair of injured solid organ with subsequent repair of aorta  high morbidity and risk of post-splenectomy sepsis syndrome 3. Clamp-and-sew method for aortic repair  cross-clamp time

Discussion2 No increase in the rate of NOM failure for solid organ injury when partial bypass with full heparinization were used Low-grade liver and spleen injury can be anticoagulated acutely with little or no risk of delayed hemorrhage Conclusion: An aortic injury in association with low-grade liver or spleen injuries can be repaired acutely using partial bypass with full heparinization safely and effectively Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass

Study Limitations Retrospective, deals with grade I or II solid organ injury only The safety of heparinizing patients with higher grades of liver or spleen injuries (III–V) was not studied, and no conclusions can be drawn for those patients The high incidence of concomitant injuries, specifically, head injury and fractures, was not addressed

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Aorta L/S Group

Aorta L/S vs. L/S

Aorta L/S vs. Aorta

Complications Similar overall complication rates (45% vs. 32%, p = NS)