A 55-year-old man is brought to the emergency department after falling from a 20-ft (6.2-m) height. The patient was leaning over a second-story roof to hang Christmas lights when he lost his footing and fell forward. Although he partially braced his fall with outstretched arms and legs, his body hit the pavement with full force. The patient has severe chest and back pain. Blood pressure is 162/90 mm Hg in the left arm, pulse is 118/min, and respirations are 24/min. On physical examination, the patient is alert but appears scared. His voice is hoarse when he tries to speak. The pupils are symmetric and reactive to light, and the trachea is midline. There is bruising over the sternum, which is tender to palpation. Breath sounds are symmetric bilaterally, and heart sounds are normal with no murmurs. The abdomen is soft and nontender. There are superficial abrasions on the patient's palms and knees. The lower extremities are cool to touch with diminished femoral pulses bilaterally. Which of the following is most likely to confirm the diagnosis in this patient?

Question

A 55-year-old man is brought to the emergency department after falling from a 20-ft (6.2-m) height.  The patient was leaning over a second-story roof to hang Christmas lights when he lost his footing and fell forward.  Although he partially braced his fall with outstretched arms and legs, his body hit the pavement with full force.  The patient has severe chest and back pain.  Blood pressure is 162/90 mm Hg in the left arm, pulse is 118/min, and respirations are 24/min.  On physical examination, the patient is alert but appears scared.  His voice is hoarse when he tries to speak.  The pupils are symmetric and reactive to light, and the trachea is midline.  There is bruising over the sternum, which is tender to palpation.  Breath sounds are symmetric bilaterally, and heart sounds are normal with no murmurs.  The abdomen is soft and nontender.  There are superficial abrasions on the patient's palms and knees.  The lower extremities are cool to touch with diminished femoral pulses bilaterally.  Which of the following is most likely to confirm the diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8a4_f997_bc81_537d4ebf01eb_MD0003_00 This patient with evidence of blunt chest trauma (eg, sternal bruising) following rapid deceleration (fall >3 m [10 ft] onto pavement) is at risk for blunt thoracic aortic injury (BTAI). Rapid deceleration exerts stretching, shearing, and torsional forces capable of rupturing the aorta. The aortic isthmus-the transition zone between the relatively mobile ascending aorta/arch and the fixed descending aorta-is particularly vulnerable to these forces and the most common site of BTAI. aortic isthmus Complete aortic rupture (ie, tear of the intima, media, and adventitia) typically results in rapid exsanguination and death. This patient who survived the fall likely has an incomplete rupture (ie, tear of the intima ± media), which may result in: Creation of a secondary, false lumen similar to aortic dissection Creation of an obstructive intimal flap or intramural hematoma that impedes distal blood flow (pseudocoarctation), resulting in proximal hypertension and distal hypotension (eg, upper extremity hypertension with diminished femoral pulses) Expansion of the adventitia under high-flow pressure, causing compression/stretching of surrounding structures such as the left recurrent laryngeal nerve (eg, hoarse voice) CT angiography of the chest is highly sensitive and specific for thoracic aortic injury and is readily available. Transesophageal echocardiography (TEE) can also evaluate the thoracic aorta but requires an experienced echocardiographer. Transthoracic echocardiography (TTE) does not adequately visualize the thoracic aorta, which progressively becomes a more posterior anatomical structure (closer to the esophagus) as it arches and transitions into the descending aorta (Choice F). Incomplete rupture should prompt emergent surgical evaluation. (Choice A) Chest tube placement is indicated for pneumothorax or effusion (eg, hemothorax), which are unlikely in this patient with bilateral symmetric breath sounds. (Choice C) Esophagography with water-soluble contrast evaluates for esophageal perforation. Although esophageal rupture can occur with blunt chest trauma and cause severe chest and back pain, it does not cause differential blood flow between the upper and lower extremities. (Choice D) Flexible bronchoscopy visualizes the proximal airway lumen and can diagnose tracheobronchial injury, which classically causes pneumothorax and/or pneumomediastinum, severe respiratory distress, diminished breath sounds, and/or crepitus (subcutaneous emphysema). (Choice E) Pericardiocentesis treats pericardial tamponade. Acute pericardial tamponade would cause decreased cardiac output with global hypotension (rather than upper extremity hypertension with diminished femoral pulses) and muffled heart sounds. Educational objective: Patients with trauma following rapid deceleration are at risk for blunt thoracic aortic injury. Signs may include upper extremity hypertension with lower extremity hypotension (pseudocoarctation) and/or a hoarse voice (left recurrent laryngeal nerve stretching). References: Vascular injuries after blunt chest trauma: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/19751511) Thoracic aortic aneurysm as a cause of Ortner's syndrome-a case series. (http://www.ncbi.nlm.nih.gov/pubmed/27495889)

A 55-Year-Old Man Is Brought to the Emergency Department After