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Injuries to the thoracic great vessels can be a significant cause of morbidity and mortality. Large vessels in the hilum of the lung include the pulmonary artery and vein. The great vessels also include the vena cava, aorta, innominate artery, subclavian artery, and subclavian vein. The mortality from injuries to the subclavian artery is approximately 5% if patients who are moribund on admission to the Emergency Department are excluded.1 However, the mortality from injury to the vena cava and the pulmonary vessels is over 60%.2 While over 85% of patients with penetrating injuries to the thorax are stable, the remainder present in varying levels of hypovolemic shock. They may have bled externally or into the chest. Each hemithorax can hold up to one-half of an individual’s blood volume. In these cases, an Emergency Department thoracotomy may be performed for hypovolemic shock.
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ANATOMY AND PATHOPHYSIOLOGY
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Injury to the thoracic great vessels may be due to blunt trauma, diagnostic procedures, iatrogenic causes, or penetrating trauma. Crush injuries, deceleration injuries, motor vehicle versus pedestrian collisions, and penetrating thoracic injuries may all signify an injury to a thoracic great vessel. The vessels that are most commonly injured include the aorta, innominate artery, pulmonary vein, and venae cavae.
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The portable anteroposterior chest radiograph is the initial radiographic screening. It may reveal loss of the aortic knob contour, left-sided pleural effusions, mediastinal widening, nasogastric tube deviation, or tracheal deviation, all of which suggest injury to a great vessel. Other findings suggestive of great vessel injury include depression of the left mainstem bronchus, left apical capping, narrowing of the carinal angle, sternal fractures, opacification of the aortopulmonary window, and widening of the paraspinous stripe.
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Numerous physical examination findings are suggestive of a thoracic great vessel injury. Asymmetric pulses or unequal blood pressures between the extremities are quick and simple to evaluate. Hypotension may be due to internal or external hemorrhage. Steering wheel contusions, sternal fractures, thoracic spine fractures, and a left-sided flail chest signify potential intrathoracic injury. A thoracic outlet hematoma or a hoarse voice can occur from injury to the aorta or one of its major branches. Paraplegia may be due to hypotension or an aortic disruption.
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Attempts should be made to control any laceration or rupture of the thoracic great vessels.3,4
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There are no absolute contraindications to temporarily controlling any hemorrhage from a thoracic great vessel after performing a thoracotomy (Chapter 54). The thoracotomy should not be performed if the patient has obvious signs of death, no vital signs in the field, or no vital signs for over 15 minutes. Refer to Chapter 54 for a discussion in which a thoracotomy is contraindicated, as any hilum or great vessel repair is also contraindicated. A pericardial tamponade or ...