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A 35year male presented to ER after high speed motor vehicle accident. His mother died on the spot who was sitting to next to driver seat. He was fully conscious but anxious with cold sweating and air hunger. His obvious injuries were closed fracture femur. His vitals were heart rate 88/min, regular, NIBP 160/100 mmHg and respiratory rate 20/min and SpO2 98%. His all peripheral pulses were well felt. Air entry was present bilaterally on auscultation. Chest x-ray was performed which showed widened mediastinum. CT scan done immediately revealed double aortic transaction with minimal haemothorax.
In developing world with limited resources, trained and experienced surgeons, facility and financial restraints management of these complex injuries is challenging. Challenges include overall management particularly long-distance transport and haemodynamics stabilization.
Widened mediastinum with other findings suggestive of aortic injury on plain X-ray chest and CT scan with double transaction and haemothorax.
Our team was not having enough experience for aortic surgery thus patient was transferred to an advanced cardiac centre which was 350 kms away via road. Metorolol 5+5 mg was administered intravenously slowly over 15-20 minutes and sodium nitroprusside infusion was instituted to reduce rate of rise of pressure to prevent further injury and exsanguation. In advanced cardiac Centre, vascular stenting was failed and then open surgical repair was done. He had wonderful recovery and then fracture femur was fixed after 4-5 days. He is on regular follow up.
Major traumatic vascular injuries can be catastrophic. Patients with aortic injury who reach hospital are is relatively clinically asymptomatic. High index of suspicion is important as the presentation can be asymptomatic to variable clinical picture.
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