Blunt Thoracic Aortic Injury

Original Date: 07/2025

Patients who suffer a blunt aortic injury typically present after deceleration-type injuries and with severe chest trauma. Blunt aortic injury is diagnosed by CT Chest with IV contrast.

Injury Grading:

  • Grade 1 – intimal tear
  • Grade 2 – intra-mural hematoma
  • Grade 3 – pseudoanuerysm
  • Grade 4 – pseudoanuerysm with rupture

Management of Blunt Aortic Injury

Initial Medical Management:

  • Therapeutic targets are: SBP ≤120 mmHg and pulse ≤90 bpm.
  • If SBP >120 mmHg or pulse >90 bpm, start esmolol 500 micrograms/kg bolus over 30 seconds.
  • Start esmolol infusion at 50 micrograms/kg/min
  • Titrate drip to achieve SBP target.
  • Oral beta-blockers may be given in stable patients able to take pills by mouth.

Treatment:

  • Grade 1 injuries are generally managed medically with repeat imaging as indicated.
  • Grade 2 injuries may be managed medically or by TEVAR.
  • Grade 3 injuries without high risk features should undergo TEVAR within 24 hours after admission.
  • Grade 3 injuries with high risk features should undergo emergency TEVAR.
    • High risk features:
      • Aortic arch hematoma
      • Ascending aortic, aortic arch, or great vessel involvment
      • Mediastinal hematoma causing mass effect
      • Posterior mediastinal hematoma >10 mm
      • Lesion to normal aortic diameter >1.4
      • Large left hemothrorax
  • Grade 4 injuries should undergo emergency TEVAR.

Medical Management:

  • Anti-platelet therapy:
    • Given for all grade injuries and for medically and surgically treated patients as allowed by concomitant injuries and medical problems
    • Dose: 81 mg per day.
      • Non-operative management: continue until lesion resolves on imaging
      • After TEVAR: continue for 30 days post operatively
  • Blood pressure and heart rate targets:
    • Non-operative management: transition esmolol drip to oral beta blockers to goal SBP <120 mmHg and pulse <90 bpm. Continue until lesion resolves on imaging.
    • After TEVAR: no blood pressure or heart rate management required.