Asian Cardiovasc Thorac Ann 2005;13:200
© 2005 Asia Publishing EXchange Ltd
Blood Pressure Control for the Patients with Blunt Aortic Trauma
Hitoshi Hirose, FICS
Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
This letter refers to the article by Lancey et al in the Asian Cardiovascular and Thoracic Annals, entitled "Factors affecting early exsanguination and death in blunt traumatic aortic trauma".1 They reviewed 80 patients who sustained aortic blunt trauma over a 20-year period. Since their findings are very confusing, I would like to ask several questions to understand their study better.
- The studied patients appeared to be consecutive patients coming into the emergency department (ED) with a diagnosis of blunt aortic trauma, because there were no exclusion criteria described in this study. The report included patients who had come to the ED with no blood pressure (BP) and never regained, because the authors indicated that admission systolic BP ranges were 0–200 mm Hg and maximum systolic BP ranges were 0–225 mm Hg. I believe that these patients were transported by paramedics in extremis and confirmed as dead in the ED. I suspect that 7 patients who were exsaguinated and expired in the ED were in this category of patients. I doubt these 7 patients underwent angiographic study. The patients with no vital signs on arrival at ED may have had exsanguinated from the aorta or sustained other fatal injuries developing during the period of transport from the scene to the hospital. If an investigator includes such patients with no blood pressure on arrival to the ED in the analysis, absence of blood pressure would have a strong correlation with death or exsanguination, and thus it skews the data.
- Their study demonstrated that patients with higher blood pressure had better outcomes. This raises a question of blood pressure control in patients with aortic trauma. As the authors indicated in the discussion section, anti-hypertensive therapy and delaying of aortic repair with success have been reported, including at our institution.2–4 Strict BP control is reasonable therapy of choice to prevent exsanguination in stable patients with aortic injury, as well as in those with aortic dissection, which has a similar pathology of the aorta. A previous study demonstrated that exsanguination was only observed in patients with poor BP control.5 Since then, the concept of anti-hypertensive therapy has been accepted and became popular in late 1990s. Because the series from Lancey et al are from 1978 to 2001, I understand that two thirds of the patients may not have received any BP control regimens especially before 1990. However, I would like to ask the authors what is the current treatment of patient with aortic trauma at their institution. Do the authors use anti-hypertensive medication to lower BP to prevent free rupture? I also want to know whether the authors have changed the treatment based on their study, in other words, whether or not the authors recommend the avoidance of a beta-blocker or other anti-hypertensive medication in patients with aortic trauma because their study showed higher BP was related to lower mortality rate. Furthermore, I would like to ask the authors opinion regarding the delay of surgical repair, because the authors series demonstrated that early surgical repair does not always improve the outcome: mean hours from diagnosis to repair was 1.1 hours in non-survivors and 2.2 hours in survivors as shown in Table 6 of their report. If you agree to the purposefully delay of aortic surgery, I would like to know how the authors would manage the patients during the delay period.
- The author found that age greater than 30 years was associated with a higher mortality rate. However, Figure 1 in their presentation showed a much higher mortality rate in patients more than 50 years old. I would like to know whether or not age was still significant risk factor of death on logistic analysis, if age is analyzed as a continuous variable rather than categorical variable.
I believe these additional analyses and authors opinions will facilitate a better understanding of their study.
REFERENCES
- Lancey RA, Pezzella AT, Phillips DA. Factors affecting early exsanguination and death in blunt thoracic aortic trauma. Asian Cardiovasc Thorac Ann 2004;12:202–7.[Abstract/Free Full Text]
- Mattox KL, Wall MJ Jr. Historical review of blunt injury to the thoracic aorta. Chest Surg Clin N Am 2000;10:167–82.[Medline]
- Kwon CC, Gill IS, Fallon WF, Yowler C, Akharass R, Temes T, et al. Delayed operative intervention in the management of traumatic descending thoracic aortic rupture. Ann Thorac Surg 2002;74:S1888–91.[Abstract/Free Full Text]
- Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19:119–26.[Medline]
- Fisher RG, Oria RA, Mattox KL, Whigham CJ, Pickard LR. Conservative management of aortic laceration due to blunt trauma. J Trauma 1990;30:1562–6.[Medline]
