Chirurgie Cardiaque/cardiac Surgery Blunt Thoracic Aortic Injury (btai) : Advances in the Era of Innovation. a Review (part 2)

and its publication Guidelines for essential Trauma Care, has addressed the need and value of early coordinated, standardized care of the trauma patient2. Both stress the ABC’s, and primary/secondary survey. Tension pneumothorax, cardiac tamponade, and massive hemothorax warrant an early response in the primary survey. This requires ready availability of chest tube thoracostomy, subxyphid pericardial window, or emergency/urgent thoracotomy. The patient’s clinical status ultimately dictates the subsequent evolution of action. There are eight thoracic lethal injuries following blunt, penetrating or blast injury: progressive pneumothorax, increasing hemothorax, pulmonary contusion with ARDs, tracheobronchial injury with large air leak, blunt cardiac injury, BATi, diaphragmatic rupture, and mediastinal traverse injury102. Diagnostic studies can be precluded in the light of extreme scenarios. With few exceptions a definitive sequence of intervention is mandated103. A major decision to be made in the triage period for suspected or diagnosed BTAi is whether the accepting facility can accommodate and treat the injury, or requires transfer to a higher echelon trauma facility (level i or ii). Undertriage places the victim at higher risk, whereas overtriage increases transfer to higher level centers, with resultant greater cost and utilization of resources. The availability of advanced diagnostic studies, cardiopulmonary bypass, and endovascular stent-graft capability are important considerations. Regarding blunt thoracic trauma, emergency or resuscitative thoracotomy for cardiac arrest, when vital signs are present at the scene, and neurologically intact, has a documented survival rate ranging from 0.6 – 4.5 %23,64,65. The role in blunt trauma has not been effective, as compared to penetrating trauma101,104,105. The ATls revised guidelines are noted101: “ Patients Treatment The treatment strategy of the BTAi patient must consider a number of factors: time interval from injury to diagnosis, age, clinical status (emergent, unstable, stable), associated injuries, and underlying comorbidity. A major therapeutic challenge is treatment of the asymptomatic minimal aortic injury (MAI) (defined as an intimal flap < 1cm and no periaortic hematoma or pseudoaneurysm), and especially those with delayed referral or dignosis6,11. Given the sophistication of the aforementioned diagnostic modalities, these small lesions are being increasingly identified11. The natural history of mAi is unknown. malhotra et al.11 reported a 10% (9 patients) incidence of mAi in a series of 87 patients. of 6 discharged patients 2 had resolution of the mAi, and 3 developed small pseudoaneurysms. Delayed medical management and surveillance offer a safe and prudent approach18. however, eVsG has gained increased support in this scenario. The larger series of more extensive lesions are the present concern. mattox et al.4,13 stress the three objectives of surgical treatment : 1to prevent exsanguinations from a partial tear with a contained perivascular hematoma; 2to control blood loss from vessel wall rupture; 3and to restore vessel continuity. symbas46 proposed an early algorithm (figure 19). Downing et al49 has proposed an updated algorithm for diagnostic evaluation and treatment (figure 20). A contemporary algorithm features CT scan and eVsG playing prominent roles (figure 21). This has been hightlighted in the recent AAsT report (table 1)8, as well as the updated ATls changes with level 3 and 4 evidence (table 2)101. The ATls protocol is mandated in evaluation of suspected BTAi102. Globally, in low and middle income countries (lmiC), the essential Trauma Care Project, A C T C V T