Blunt Thoracic Aortic Injury

A. For patients with very suspicious chest radiograph with hypertension OR diagnosis of BTAI on helical chest CT or angiogram:

Start Antihypertension regimen:

1. Infuse esmolol bolus then maintenance rate for a goal BP (syst) 100-120 mmHg, heart rate <100

2. Add second agent such as Nitroprusside if BP (syst) still elevated despite esmolol

B. Treat ongoing life-threatening hemorrhage from other injuries prior to treatment of BTAI (unless patient actively bleeding from aorta).

C. Treat coagulopathy if present.

D. Once diagnosis of BTAI established consult Cardiac Surgery and evaluate the following to determine early or delayed repair.

Reasons for delayed repair:

1. Pa02/Fi02 ratio less than 150

2. CNS injuries which should be delayed: a. massive contusion b. evidence of shift on Head CT c. large areas of intracerebral blood d. high ICP (consistently >20) e. need for systemic heparinization for full bypass felt to be contraindicated by Neurosurgery.

3. Ongoing major transfusion requirement or coagulopathy

4. Massive, open, contaminated wounds or burn where likelihood of wound sepsis is high.

E. If patient to be delayed for longer than 48 hours:

1. Continue beta-blocker therapy, convert to long-acting agent (labetalol or atenolol)

2. Add secondary long acting antihypertensives as necessary

3. BP (syst) may be liberalized at 7 days to 150-160 mmHg

4. Physical therapy may begin at day 5

F. Any additional concerns or problems should be discussed at the attending level between the TB and Cardiac surgeons.