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Aortic Disruption (Traumatic)


Thomas G. Weiser

, MD, MPH, Stanford University School of Medicine

Reviewed/Revised Apr 2022 | Modified Sep 2022
Topic Resources

The aorta can rupture completely or incompletely after blunt or penetrating chest trauma. Signs may include asymmetric pulses or blood pressure, decreased blood flow to the lower extremities, and precordial systolic murmur. Diagnosis is often suspected because of the mechanism of injury and/or chest x-ray findings and confirmed by CT, ultrasonography, or aortography. Treatment is open repair or, more commonly, stent placement.

Etiology of Traumatic Aortic Disruption

With blunt trauma, the usual mechanism is a severe deceleration injury; patients often have multiple rib fractures, 1st and/or 2nd rib fractures, or other manifestations of severe chest trauma.

With penetrating trauma, the usual wound traverses the mediastinum (eg, entering between the nipples or the scapulae).

Pathophysiology of Traumatic Aortic Disruption

Complete rupture causes rapid death by exsanguination. Partial disruption with contained rupture tends to occur near the ligamentum arteriosum (see figure Most partial ruptures of the aorta occur near the ligamentum arteriosum Most partial ruptures of the aorta occur near the ligamentum arteriosum Most partial ruptures of the aorta occur near the ligamentum arteriosum ) and to have blood flow maintained, usually by an intact adventitial layer. However, partial ruptures may also cause limited mediastinal hematomas.

Most partial ruptures of the aorta occur near the ligamentum arteriosum

Most partial ruptures of the aorta occur near the ligamentum arteriosum

Symptoms and Signs of Traumatic Aortic Disruption

Patients with traumatic aortic disruption typically have chest pain.

Signs can include upper extremity pulse deficits, a harsh systolic murmur over the precordium or posterior interscapular space, hoarseness, and evidence of impaired blood flow to the lower extremities, including decreased pulse strength or blood pressure in the lower extremities compared to the upper extremities.

Diagnosis of Traumatic Aortic Disruption

  • Aortic imaging

Traumatic aortic disruption should be suspected in patients with a suggestive mechanism or suggestive findings. Chest x-ray is done.

Suggestive chest x-ray findings include the following:

  • Widened mediastinum (high sensitivity except among older patients)

  • 1st or 2nd rib fracture

  • Obliteration of the aortic knob

  • Deviation of the trachea or esophagus (and thus also any nasogastric tube) to the right

  • Depression of the left mainstem bronchus

  • Pleural or apical cap

  • Hemothorax, pneumothorax, or pulmonary contusion

However, some of these suggestive chest x-ray findings may not be present immediately. Also, no finding or combination of findings is sufficiently sensitive or specific; thus, many authorities recommend aortic imaging for all patients who have had a severe deceleration injury, even in the absence of suggestive findings on examination or chest x-ray.

The aortic imaging study of choice varies by institution. Studies that are reasonably accurate include the following:

If patients are not stable enough to undergo any of the available imaging studies and the cause of shock is suspected to be traumatic aortic disruption, immediate surgery is indicated.

Treatment of Traumatic Aortic Disruption

  • Blood pressure control

  • Surgical repair or stent placement

In patients with traumatic aortic disruption, fluid resuscitation is indicated, but impulse control therapy (decreasing heart rate and blood pressure, usually with a beta-blocker) should be started once other sources of hemorrhage have been excluded. Targets are heart rate 90 beats/minute and systolic blood pressure 120 mm Hg; and patients should not perform a Valsalva maneuver. Measures should be taken to avoid coughing and gagging if patients require endotracheal intubation (eg, pretreatment with 1 mg/kg lidocaine IV) or nasogastric intubation (eg, avoiding any resistance to tube passage).

Previously, definitive treatment was immediate operative repair, but endovascular stent placement is now the treatment of choice. Surgical repair can be delayed while evaluating and treating other potentially life-threatening injuries.

Key Points

  • Partial disruption of the aorta should be considered in patients with a chest injury caused by severe deceleration.

  • Chest x-ray abnormalities are common but may be absent and are often nonspecific; better aortic imaging studies include CT angiography, aortography, and transesophageal echocardiography.

  • Control heart rate and blood pressure (usually with a beta-blocker) and place an endovascular stent or do operative repair.

Drugs Mentioned In This Article

Drug Name Select Trade
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, Gold Bond, LidaMantle, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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