Survival of Combined Descending Thoracic Aortic Transection and Diaphragmatic Rupture in a Pediatric

1
Survival of Combined Descending Thoracic Aortic
Transection and Diaphragmatic Rupture in a
Pediatric Patient

• Jason L Oliphant, MD, Marc G Schlatter, MD
• Edward T Murphy, MD, Neal D Hillman, MD
• Zachary A Horton, MD
• Grand Rapids Medical Education and Research
  Center/ Michigan State University General Surgery
  Residency
• Spectrum Health DeVos Childrens Hospital

2
Introduction

• Traumatic Diaphragmatic Rupture
• Very rare-0.07-3 among all pediatric trauma
  patients 1-4
• Pediatric mortality 15-401,3-5
• Almost always from associated injuries
• Aortic Transection
• Even more rare-0.05-1 among pediatric blunt
  chest trauma patients6-10
• Pre-Hospital Pediatric mortality 90-936,9
• In-Hospital Pediatric Mortality 67-8711

3
Pre-Arrival Course

• 0445 14 year-old unrestrained rear-seat
  passenger in high-speed MVA
• Loss of consciousness per patient
• Driver died at scene

4
Emergency Department Course

• 0554 Trauma Bay
• Multiple other severely injured patients from
  same accident
• Patient talking
• Coarse rhonchi over left hemithorax fair effort
  bilaterally
• HR 136, BP 145/60
• Gross deformity of Right thigh
• Abdomen tender
• Intact and symmetric peripheral pulses

5
Initial Chest X-Ray (0555)
6
Post-Thoracostomy X-Ray (0620)
7
Imaging findings

• Left Diaphragmatic Hernia
• Right leg X-Rays displaced femur fracture and
  tibial shaft fracture
• 0645 CT Scans

8
CT Thorax
9
CT Thorax
10
CT Thorax
11
CT Thorax
12
CT Thorax
13
CT Thorax
14
CT Abdomen/Pelvis
15
CT Abdomen/Pelvis
16
CT Abdomen/Pelvis
17
Interventions

• 0640 HR 140, BP 122/65, less responsive
• 0705 1 unit packed red blood cells
• 0710 Pediatric Intensive Care Unit
• Intubated
• 0735 to Operating Room
• 0820 Laparotomy
• Stomach, spleen, bowel in Left chest
• Splenectomy
• Repair of 12cm Left posterior diaphragmatic
  rupture

18
Interventions

• 1136 Left Thoracotomy
• Extensive mediastinal hematoma
• Partial bypass
• Nearly circumferential aortic transection just
  distal to Left Subclavian Artery
• 14mm x 4cm Dacron interposition graft
• 1600 Intramedullary nail Right femur
• Open reduction and internal fixation of Right
  tibia

19
Interventions

• Intra-operative infusions
• Five units packed red blood cells
• Six units fresh frozen plasma
• Six units platelets
• Ten units cryoprecipitate
• norepinephrine

20
Post-Operative Course

• Nine days on ventilation
• 11 total days in intensive care
• 14 total hospital days
• Seven days in acute rehabilitation
• Two months post-op
• Small bowel obstruction
• Exploratory laparotomy with lysis of adhesions

21
Review of Literature

• Chugtai (2007) and Rizoli (1994)12,13
• associated injury complex
• 7.4 (of 9,734 blunt traumas) of adults with
  diaphragm rupture had aortic injury-a 6-fold
  increased risk
• Estrera (1979)14 autopsy series of patients dead
  on arrival of blunt trauma
• 16 (5) of 307 had diaphragmatic rupture
• 15 (94) of those 16 had thoracic aortic injury

22
Review of Literature

• Ramos (2000)3 1 (7) of 15 children with
  diaphragmatic rupture had aortic injury-died
• Koplewitz (2000)4 2 (12) of 16 -both died
• (one of them was the patient in Ramos sample)
• Eddy (1990)9 3 (23) of 13 children with
  thoracic aortic rupture had diaphragmatic rupture
• all three died

23
Review of Literature

• Bergman (1990)15 Autopsy study of 322 pediatric
  patients
• 16 (5) aortic injuries
• 6 (2) diaphragmatic ruptures
• Not specified whether in same patients

24
Series of Blunt Diaphragmatic Rupture with
Associated Aortic Injuries Including Children
25
Series of Blunt Thoracic Aortic Injury with
Associated Diaphragmatic Rupture Including
Children
26
Factors in Survival

• Age and Physiologic Reserve
• Prompt identification of injuries
• Presence of appropriate specialists

27
Conclusions

• Blunt diaphragmatic injury is a marker for more
  severe injuries
• Traumatic aortic injuries carry an extremely high
  mortality
• This is the first reported case to our knowledge
  of a pediatric patient surviving combined
  diaphragmatic and aortic injuries

28

• References
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