Diagnostic Imaging Pathways - Thoracic Aorta Blunt Trauma
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This pathway provides guidance on the imaging of adult patients at risk of aortic injury following blunt trauma.
Date reviewed: December 2018
Date of next review: December 2021
Published: July 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image Gallery
Note: These images open in a new page| 1 |  |
Blunt Thoracic Aortic Injury Image 1 (Chest radiography): The classical radiographic signs of a traumatic disruption of the aorta are shown including a widened mediastinum, depressed left main bronchus and left apical cap. |
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Blunt Thoracic Aortic Injury Image 2a, 2b and 2c (CT Angiography): Evidence of an intimal flap and full-thickness rupture of the thoracic aorta at the level of the aortic isthmus (arrows). Subcutaneous emphysema is seen bilaterally with contusions to the left lung. |
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| 2d |  |
Image 2d and 2e (Aortography): Aortic rupture is confirmed by evidence of delayed contrast flow in the region of the aortic isthmus (arrow) which is best seen in image 2e, where the area of injury retains contrast and appears darker compared to the rest of the aorta. |
| 2e |
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Teaching Points
Teaching Points
- Blunt thoracic aortic injuries are rare but catastrophic. Presentation can be variable so a high index of suspicion is required
- Contrast-enhanced CT is the definitive investigation for the diagnosis and exclusion of thoracic aortic injury, however it is not necessarily required in all patients with blunt chest trauma
- The initial screening tool for blunt thoracic trauma is a chest radiograph, which may not exclude blunt thoracic aortic injury but may demonstrate other life-threatening injuries. CXR is complementary to more definitive imaging studies
- Although new abnormalities on CXR are not specific for aortic injury, findings should be followed up with CT
- In patients with a normal or equivocal CXR, the decision to proceed to CT should be based on clinical judgement, taking into account the mechanism of injury, patient factors, clinical findings, results of other investigations and disposition
- Invasive aortography is generally reserved for therapeutic purposes
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Thoracic Aorta Blunt Trauma
- Common cause of fatalities at the scene of the accident. Prompt diagnosis and treatment are essential on admission in survivors 1-4
- Over 90% of injuries occur at the aortic isthmus. Most of the rest occur in proximal ascending aorta 1-4
- Prompt diagnosis depends on the level of clinical suspicion and imaging 1-4
- Usual mechanism of injuries include sudden deceleration or crush injuries to the chest causing shearing or bending forces to thoracic aorta, 1-4 such as high-speed road trauma >60km/h or falls from height
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Plain Radiography (CXR)
- Initial screening study for evaluation of blunt thoracic trauma 4-7
- In the context of blunt trauma where there is concern for spinal injuries, this is usually supine
- CXR alone is generally not considered sufficient to exclude aortic injury 8 but it is rapidly available and is complementary to more definitive studies. 9 Other injuries requiring immediate management such as haemothorax and tension pneumothorax are readily demonstrated on CXR 10
- Findings on CXR can be suggestive of mediastinal haematoma, however it is not a specific sign. Mediastinal haematoma in trauma can be due to venous bleeding or an adjacent spine or sternal fracture, with one study reporting only 3% of positive or equivocal CXR findings representing traumatic aortic injury 11
- Although CXR findings are not specific for aortic injury and there is a large proportion of false positives, proceeding to CTA is indicated if suggestive features are present 6,12,13
- Features suggestive of mediastinal haematoma on CXR include: 4,5,14
- mediastinal widening (>8cm when supine or >6cm when upright)
- obscuration of aortic arch margin
- deviation of trachea to the right
- deviation of nasogastric tube to the right
- depressed left main bronchus
- loss of aorto-pulmonary window
- widening of paraspinal stripes
- left apical cap, left haemothorax
- Aortic injury may be directly suggested by:
- irregularity or blurring of the aortic knob contour
- aortic knob enlargement
- Blunt aortic injuries are also associated with: 14
- first or second rib fractures
- clavicle, sternal or thoracic spine fractures
- A combination of signs is more reliable than a single sign 4
- Some studies have demonstrated good negative predictive value of specific CXR signs, 12,15 however, CXR alone does not have sufficient sensitivity to rule out traumatic aortic injury
- Other studies have reported that up to two-thirds of patients with blunt aortic injury may have no mediastinal abnormalities on CXR, even after focussed re-review 10,16
- Erect PA CXRs are superior to portable AP CXRs for imaging the mediastinum 17,18 and this should be performed where possible, such as in stable patients where supine and/or AP images have been equivocal
- In the trauma setting, often only supine AP CXRs are possible which makes the assessment of the mediastinum less accurate
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Risk Factors for Blunt Thoracic Aortic Injury
- Currently, the decision to proceed to CT must be based on clinical judgement, taking into account the mechanism of injury, patient risk factors, clinical signs and symptoms, CXR findings, other investigations and disposition
- It is widely accepted that the majority of blunt aortic injuries are caused by high energy mechanisms with rapid deceleration of the thorax, including motor vehicle crashes, pedestrian vs car, falls and crush injuries. 19-25 Overall, blunt aortic injury is uncommon, occurring only in approximately 1% of all vehicular high-speed accidents 23
Selective chest CT
- Although the use of chest CT is now widespread, there is disagreement on whether chest CT should be routinely performed in all patients with a history of blunt trauma 29,30
- Most authors recommend in high clinical suspicion for blunt thoracic aortic injury, 22,31,32 however the variable presentation of injuries makes it challenging to determine which patients require CT 9,23,33,34
- Several studies have found clinical signs and symptoms to be unreliable for ruling out blunt thoracic aortic injury. A third to half of patients may have minimal or no external signs of chest trauma 35,36
- Half of patients with blunt thoracic aortic injury may have normal vital signs at presentation, 34,37 potentially leading to a delay in diagnosis
- A prospective study found that clinicians’ suspicion for any blunt chest injury did not strongly correlate with the presence of injury on subsequent CXR, suggesting that subjective assessment alone does not always reliably determine the need for imaging 38
- Fear of missing potentially life-threatening injuries has led to increased use of chest CT, including as part of the “pan scan”, however this approach has its disadvantages, including:
- Increased risk of radiation-induced cancer, particular in young populations 30,39
- Increased cost 30
- Increased time in emergency departments 40
- No increase in the number of detected life-threatening injuries, despite routine CT use. 40 A number of studies have reported that routine chest CT rarely identifies injuries that would have changed management. 41-43 Common occult injuries detected on CT include small pulmonary contusions, rib fractures and small pneumothoraces not requiring chest drain insertion
- Many guidelines recommend against the excessive use of CT when it is not warranted, however there are no specific criteria 7,32,44
Increasing the efficiency of CT use
- Observational studies have identified features that were significantly associated with significant thoracic injuries requiring intervention, including thoracic aortic injuries. A number of authors have attempted to define clinical decision making tools that identify patients at low risk of thoracic injury in blunt chest trauma, using a combination of clinical findings, mechanism of injury and CXR findings
- Use of these rules aims to reduce the number of normal chest CTs performed
- These clinical decision rules are yet to be externally validated
- A limitation of these studies is that they do not identify whether CT findings change management compared with CXR findings alone
- Currently, there are no clinical decision rules to identify which patients, with injuries on CXR, will not benefit from additional CT
- Kaiser et al found a number of factors increased the likelihood of occult CT findings in patients with normal CXR: 45
- Abbreviated injury score of 3 or more
- Pelvic or extremity abbreviated injury score of 2 or more
- Age over 30 years
- Male sex
Clinical decision rules to predict clinically significant injury on chest CT
| Clinical decision rule | Derivation population | Criteria | Implication | Accuracy |
|---|---|---|---|---|
| Traumatic aortic injury score (TRAINS) 26 | Derivation cohort n = 380. Validation cohort n = 260. Injury severity score >15 | 1.Widened mediastinum = 4 2. Hypotension <90mmHg = 2 3. Long bone fracture = 2 4. Pulmonary contusion = 1 5. Left scapula fracture = 1 6. Haemothorax = 1 7. Pelvic fracture = 1 | TRAINS score of 4 or more should progress to CT to rule out thoracic aortic injury. If less than 4, can proceed to CT if there are other indications for chest or abdominal CT | Sensitivity 92.3%, specificity 85.1% |
| NEXUS Chest CT-All and Chest CT-Major 46 | Derivation cohort n = 6002. Validation cohort n = 5475. >14 years, blunt trauma within 6h of ED presentation | 1. Abnormal CXR 2. Distracting injury 3. Chest wall tenderness 4. Sternum tenderness 5. Thoracic spine tenderness 6. Scapula tenderness 7.(Chest CT-All only) Rapid deceleration mechanism (fall from >6m, motor vehicle crash >40mph or 64km/h with sudden deceleration) | If all criteria are absent may forego CT. If one or more criteria present, cannot exclude thoracic injury but does not indicate need for chest CT - presence of one criterion is associated with prevalence of major clinical injury of 1.9-3.8% 31 | Chest CT-Major - sensitivity 99.2% and specificity 31.7% for major injury. Sensitivity 90.7% and specificity 37.9% for major or minor injury. Chest CT-All - Sensitivity 99.2% and specificity 20.8% for major injury. Sensitivity 95.4% and specificity 25.5% for major or minor injury |
| SCRAP rule 48 | Derivation cohort n = 434. Validation cohort n = 180. GCS >8, age ≥16 years, Injury Severity Score >12, no paralysis with blunt chest injury | 1. Saturation <95% on room air or <98% on any supplemental oxygen 2. Chest radiograph abnormal 3. Respiratory rate ≥25 4. Chest auscultation 5. Thoracic palpation | Absence of all criteria may rule out major thoracic injury | Sensitivity 100%, specificity 44.7% |
| Brink et al 49 | Derivation cohort n = 1047 ≥16 years | 1. Age ≥55 years 2. Abnormal physical examination chest 3. Abnormal physical examination of the thoracic spine 4. Altered sensorium 5. Abnormal conventional chest radiography 6. Abnormal thoracic spine radiograph 7. Abnormal radiograph of pelvis and abdominal ultrasonography 8. Base Excess less than -3 mmol/l 9. Haemoglobin less than 6 mmol/l (97g/L) | Presence of any criterion predicts presence of injury on any chest CT, including clinically relevant injury occult on CXR. In patients with no positive predictors, only 2% had clinically significant injuries | Sensitivity 95%. Specificity 31% |
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Computed Tomography (CT)
- Contrast-enhanced multislice CT is the recommended modality to definitively diagnose or rule out blunt thoracic aortic injury 13,14
- Invasive catheter aortography was previously the gold standard, however it is now reserved for patients requiring endovascular management
- Older studies have reported high sensitivity approaching 100% and specificity (>96%) for detecting direct and indirect signs of thoracic aorta injuries. 11,50-54 Modern CT scanners have even higher spatial resolution, as well as faster acquisition time
- Direct signs of aortic injury include: 55,56
- intimal flaps
- pseudoaneurysm
- intramural haematoma
- intraluminal thrombi
- contour abnormalities
- pseudocoarctation of the aorta
- contrast material extravasation
- Mediastinal haematoma separated from the aorta is often venous, but aortic injury is the primary concern; it may also be due to extra-aortic injury (e.g. common carotid or subclavian artery injury) 55
- Advantages
- Fast, non-invasive, safe test
- Ability to distinguish mediastinal blood from other causes of mediastinal widening detected on initial chest radiographs e.g. artefacts of magnification, mediastinal fat, or anatomical variation
- May identify injuries that are occult on CXR, including small pneumothoraces, haemothoraces, pulmonary contusions and fractures, however there is question how many occult findings change management. Read more here
- Limitations
- Requires use of iodinated intravenous contrast
- Exposure to ionising radiation
- Some patients may be too unstable to be moved to CT
- Ductus diverticulum or complicated atherosclerotic plaque may mimic thoracic aortic injury 56
- Magnetic resonance angiography (MRA) has limited practicality due to availability and long acquisition times, but can be an alternative to CT in select cases where iodinated contrast is contraindicated
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Transoesophageal Echocardiogram (TOE) and Transthoracic Echocardiogram (TTE)
- The role of TOE in blunt thoracic trauma has generally been replaced by CT as chest CT has a wider field of view and may be performed at the same time as CT of other areas, however TOE may be a useful adjunct in some situations 14
- The reported sensitivities of TOE range from to 56-100% and specificity ranging from 89-99% 57,58
- Because of previously reported lower sensitivities, TOE may not be recommended as a first-line investigation in the trauma setting and is not recommended to rule out thoracic aortic injury 14
- However, TOE may be advantageous to assess patients who are too unstable to undergo CT 14
- TOE can also assess for the presence of cardiac injuries and cardiac function
- Advantages: 14
- Can be performed at the patient bedside
- Accurate to assess region of aortic isthmus, most common region of blunt aortic injury
- No use of contrast material
- No exposure to ionising radiation
- Can assess cardiac function and cardiac injuries
- Disadvantages
- Difficulty assessing distal ascending aorta and arch vessels
- Operator dependent
- May not be suitable for patients with facial, C-spine, oropharynx or oesophageal injuries
- Semi-invasive procedure requiring sedation
Transthoracic Echocardiogram (TTE)
- TTE is not recommended as a definitive imaging test for blunt aortic injuries, however it may be useful to assess for cardiac injury in patients with hypotension or arrhythmias, in conjunction with biomarkers 14,59
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
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- Fishman JE. Imaging of blunt aortic and great vessel trauma. J Thorac Imaging. 2000;15(2):97-103. (Review article). View the reference
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- Wintermark M, Wicky S, Schnyder P. Imaging of acute traumatic injuries of the thoracic aorta. Eur Radiol. 2002;12:431-42. (Review article) View the reference
- Mirvis SE, Bidwell JK, Buddemeyer EU, Diaconis JN, Pais SO, Whitley JE, et al. Value of chest radiography in excluding traumatic aortic rupture. Radiology. 1987;163(2):487-93. (Level III evidence). View the reference
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- Gutierrez A, Inaba K, Siboni S, Effron Z, Haltmeier T, Jaffray P, et al. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury. 2016;47(1):32-6. (Level III evidence). View the reference
- Mirvis SE, Shanmuganathan K, Miller BH, White CS, Turney SZ. Traumatic aortic injury: diagnosis with contrast-enhanced thoracic CT--five-year experience at a major trauma center. Radiology. 1996;200(2):413-22. (Level III evidence). View the reference
- Harris JH, Jr., Harris WH, Jain S, Ferguson AY, Hill DA, Trahan AM. To reduce routine computed tomographic angiography for thoracic aortic injury assessment in level II blunt trauma patients using three mediastinal signs on the initial chest radiograph: a preliminary report. Emergency radiology. 2018;25(4):387-91. (Level II-III evidence). View the reference
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- Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008;64(3):561-70; discussion 70-1. (Level III evidence). View the reference
- Demetriades D, Gomez H, Velmahos GC, Asensio JA, Murray J, Cornwell EE, 3rd, et al. Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients. Arch Surg. 1998;133(10):1084-8. (Level III evidence). View the reference
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- Malgor RD, Bilfinger TV, McCormack J, Shapiro MJ, Tassiopoulos AK. Trends in clinical presentation, management, and mortality of blunt aortic traumatic injury over an 18-year period. Vasc Endovascular Surg. 2013;47(1):19-23. (Level III evidence). View the reference
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- Mosquera VX, Marini M, Muniz J, Asorey-Veiga V, Adrio-Nazar B, Boix R, et al. Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma. Intensive Care Med. 2012;38(9):1487-96. (Level II evidence). View the reference
- Ochsner MG, Jr., Champion HR, Chambers RJ, Harviel JD. Pelvic fracture as an indicator of increased risk of thoracic aortic rupture. J Trauma. 1989;29(10):1376-9. (Level III evidence). View the reference
- Ochsner MG, Jr., Hoffman AP, DiPasquale D, Cole FJ, Jr., Rozycki GS, Webster DW, et al. Associated aortic rupture-pelvic fracture: an alert for orthopedic and general surgeons. J Trauma. 1992;33(3):429-34. (Level III evidence). View the reference
- American College of Radiology. ACR appropriateness criteria. Blunt chest trauma. 2013. (Guideline). View the reference
- Rodriguez RM, Baumann BM, Raja AS, Langdorf MI, Anglin D, Bradley RN, et al. Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations. Acad Emerg Med. 2014;21(6):644-50. (Level II evidence). View the reference
- Nagy K, Fabian T, Rodman G, Fulda G, Rodriguez A, Mirvis S. Guidelines for the diagnosis and management of blunt aortic injury: an EAST Practice Management Guidelines Work Group. J Trauma. 2000;48(6):1128-43. (Guideline). View the reference
- Glen J, Constanti M, Brohi K. Assessment and initial management of major trauma: summary of NICE guidance. BMJ. 2016;353 (Guideline). View the reference
- Ho AFW, Chua TW-L, Seth P, Tan KBK, Pothiawala S. Atypical presentation of traumatic aortic injury. Case reports in emergency medicine. 2014;2014:864301-. (Level IV evidence). View the reference
- Nik Azlan NM, Rossman H. A case of missed blunt traumatic aortic injury (BTAI). Med J Malaysia. 2017;72(3):193-4. (Level IV evidence). View the reference
- Navid F, Gleason TG. Great vessel and cardiac trauma: diagnostic and management strategies. Semin Thorac Cardiovasc Surg. 2008;20(1):31-8. (Review article). View the reference
- Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am. 2009;89(4):797-820, viii. (Review article). View the reference
- Bade-Boon J, Mathew JK, Fitzgerald MC, Mitra B. Do patients with blunt thoracic aortic injury present to hospital with unstable vital signs? A systematic review and meta-analysis. Emerg Med J. 2018;35(4):231-7. (Level I-II evidence). View the reference
- Calderon G, Perez D, Fortman J, Kea B, Rodriguez RM. Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments. J Emerg Med. 2012;43(4):568-74. (Level II-III evidence). View the reference
- Berrington de Gonzalez A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-7. (Level II evidence). View the reference
- Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007. JAMA. 2010;304(13):1465-71. (Level II-III evidence). View the reference
- Corbacioglu SK, Er E, Aslan S, Seviner M, Aksel G, Dogan NO, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury. 2015;46(5):849-53. (Level III evidence). View the reference
- Kea B, Gamarallage R, Vairamuthu H, Fortman J, Lunney K, Hendey GW, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? The American journal of emergency medicine. 2013;31(8):1268-73. (Level III evidence). View the reference
- Kaiser M, Whealon M, Barrios C, Dobson S, Malinoski D, Dolich M, et al. The clinical significance of occult thoracic injury in blunt trauma patients. Am Surg. 2010;76(10):1063-6. (Level III evidence). View the reference
- Rotondo MF, Cribari C, Smith RS. Optimal care of the trauma patient: resources for optimal care of the injured patient 2014. Chicago, IL: American College of Surgeons Committee on Trauma; 2014. p. 80. (Guideline). View the reference
- Kaiser ML, Whealon MD, Barrios C, Jr., Dobson SC, Malinoski DJ, Dolich MO, et al. Risk factors for traumatic injury findings on thoracic computed tomography among patients with blunt trauma having a normal chest radiograph. Arch Surg. 2011;146(4):459-63. (Level III evidence). View the reference
- Rodriguez RM, Langdorf MI, Nishijima D, Baumann BM, Hendey GW, Medak AJ, et al. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS Med. 2015;12(10):e1001883. (Level II evidence). View the reference
- Raja AS, Lanning J, Gower A, Langdorf MI, Nishijima DK, Baumann BM, et al. Prevalence of chest injury with the presence of NEXUS chest criteria: data to inform shared decisionmaking about imaging use. Ann Emerg Med. 2016;68(2):222-6. (Level II evidence). View the reference
- Payrastre J, Upadhye S, Worster A, Lin D, Kahnamoui K, Patterson H, et al. The SCRAP Rule: The derivation and internal validation of a clinical decision rule for computed tomography of the chest in blunt thoracic trauma. Cjem. 2012;14(6):344-53. (Level II evidence). View the reference
- Brink M, Deunk J, Dekker HM, Edwards MJR, Kool DR, van Vugt AB, et al. Criteria for the selective use of chest computed tomography in blunt trauma patients. Eur Radiol. 2010;20(4):818-28. (Level II evidence). View the reference
- Scaglione M, Pinto A, Pinto F, Romano L, Ragozzino A, Grassi R. Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma. Eur Radiol. 2001;11(12):2444-8. (Level II evidence). View the reference
- Melton SM, Kerby JD, McGiffin D, McGwin G, Smith JK, Oser RF, et al. The evolution of chest computed tomography for the definitive diagnosis of blunt aortic injury: a single-center experience. J Trauma. 2004;56(2):243-50. (Level II evidence). View the reference
- Parker MS, Matheson TL, Rao AV, Sherbourne CD, Jordan KG, Landay MJ, et al. Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries. AJR Am J Roentgenol. 2001;176(5):1267-72. (Level II evidence). View the reference
- Dyer DS, Moore EE, Ilke DN, McIntyre RC, Bernstein SM, Durham JD, et al. Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients. J Trauma. 2000;48(4):673-82; discussion 82-3. (Level II evidence). View the reference
- Bruckner BA, DiBardino DJ, Cumbie TC, Trinh C, Blackmon SH, Fisher RG, et al. Critical evaluation of chest computed tomography scans for blunt descending thoracic aortic injury. Ann Thorac Surg. 2006;81(4):1339-46. (Level II evidence). View the reference
- Weatherspoon K, Gilbertie W, Catanzano T. Emergency computed tomography angiogram of the chest, abdomen, and pelvis. Semin Ultrasound CT MR. 2017;38(4):370-83. (Review). View the reference
- Rabin J, DuBose J, Sliker CW, O'Connor JV, Scalea TM, Griffith BP. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg. 2014;147(1):143-9. (Level II-III evidence). View the reference
- Cinnella G, Dambrosio M, Brienza N, Tullo L, Fiore T. Transesophageal echocardiography for diagnosis of traumatic aortic injury: an appraisal of the evidence. J Trauma. 2004;57(6):1246-55. (Level I-II evidence). View the reference
- Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006;166(13):1350-6. (Level I-II evidence). View the reference
- Clancy K, Velopulos C, Bilaniuk JW, Collier B, Crowley W, Kurek S, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. The journal of trauma and acute care surgery. 2012;73(5 Suppl 4):S301-6. (Guideline). View the reference
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