Rupture Aortic isthmus

This 35 year old man from Philippine was involved in RTA. He arrived to AE department in hypovolaemic shock. He had a blunt trauma to the left side of the trunk. There was external contusion over the left hemithorax with diminished air entry.

Abdominal examination revealed rigid, tender abdomen with guarding especially at left hypochondrium.

Chest x-ray showed widening of the superior mediastinum and opacity on the left side denoting left-sided hemothorax.
P-A view chest

Patient was taken immediately to operating theatre. Drainage of hemothorax was performed through ICD tube to under water seal system.

Exploratory laparotomy revealed rupture spleen and rupture left diaphragmatic copula. Splenectomy was performed together with suturing of the diaphragm.

Patient improved gradually in postoperative period and regained his BP and pulse parameters. He was kept on full ventilation and his abdominal status became stable.

Few hours later, ICD tube started to drain fresh blood and collected 200 ml within 15 minutes. Again, His BP began to drop and his pulse became weak and rapid.

He was taken immediately to O.T. Left postero-lateral thoractomy was performed and the left thoracic cavity was explored. There was a transverse tear in the aortic isthmus about 2 cm in length posteriorly.

Attempts to suture the tear failed twice due to high pressure in the aorta. The anesthetist put extra effort to control the BP using Na nitroprusside infusion to maintain systolic pressure not more than 90 mm/Hg. Hence, we could suture the tear.

 The patient was sent back to ICU with full ventilation, antibiotic cover and Na nitroprusside infusion.

Patient finally did well and recovered  and his superior mediatinum regained its normal shape.
Chest P-A view after correction.

The patient  received 20 pints of blood since admission and during the surgical operation.

After 4 days, Patient developed non-homogenous ill defined opacity at the middle zone of the left lung field. It proved to be ARDS.
Chest x-ray P-A view

Unfortunately he expired within a week due to ARDS and gram negative septicemia.