Pediatric emergency medicine trisk 3714 3714

Triage
Children with known or suspected great vessel injury should be evaluated
immediately, mobilizing the highest level of trauma care available. Preparations
for both radiologic evaluation and surgical intervention should begin as soon as
the injury is suspected, as even the stable patient may deteriorate very rapidly.
Clinical Assessment
Children are usually symptomatic from associated injuries, and great vessel
injuries can easily be missed. Clinical signs may include difference in pulse
between the arms or arms and legs, thoracic ecchymosis, thoracic and back
tenderness, paraplegia, and anuria. In patients with more severe injuries,
hypotension or excessive bleeding from a chest tube may be seen. Patients with
paraplegia and back pain may be initially diagnosed with a spinal cord injury.
Unfortunately, 50% of patients with aortic injuries may have no signs pertaining
directly to that injury.
Management
Early diagnosis is imperative in patients with aortic or other great vessel injuries.
Morbidity and mortality increase threefold if operative intervention is delayed
more than 12 hours. CXR is usually the initial study performed. Findings may
include a widened mediastinum, blurred aortic knob, pleural cap, or tracheal or
nasogastric tube deviation ( Fig. 115.8 ). While a normal CXR has been reported
to have a 98% negative predictive value in excluding thoracic aortic tear,
specificity of an abnormal radiograph is poor and, given sufficient clinical
suspicion, further imaging is required to make the diagnosis. Multidetector CT
angiography has largely replaced echocardiography and aortography as the
imaging modality of choice in diagnosing aortic injury, though its test
characteristics in children are unknown. CT angiography should not be performed
routinely on children with thoracic trauma; its use should be limited to those with
high suspicion for injury to the aorta and great vessels based on clinical
presentation or results of CXR. For the stable patient with an equivocal CT or
who requires further delineation of the injury, aortography may be an appropriate
follow-up study ( Fig. 115.9 ).

Treatment of great vessel injuries varies based on degree and location of injury
and stability of the patient. Therapeutic options include fluid resuscitation and use
of beta blockers in hemodynamically stable patients, blood transfusion, and open
or endovascular repair.