Patient factors and operating room resuscitation predict mortality in traumatic abdominal aortic injury: a 20-year analysis.

BACKGROUND: Injuries to the abdominal aorta are rare and remain one of the most lethal causes of early death in trauma. The purposes of this study were to identify primary predictors of mortality and to examine the impact of a well-established operating room resuscitation protocol on survival in patients with traumatic aortic injury.
METHODS: A 20-year retrospective review was performed of medical records and autopsy reports of trauma patients admitted with confirmed injury to the abdominal aorta. Data on patient demographics, admission characteristics, operative findings, and the initial location of resuscitation were collected. The main outcome measure was death.
RESULTS: Abdominal aortic injuries were diagnosed in 60 patients. Their average age was 26.5 years, and the mean transport time was 10 minutes. The overall mortality rate (MR) was 73%. With the exclusion of 18 patients considered dead on arrival, the MR decreased to 61%. The mechanism of injury was blunt in 20% (MR 92%) and penetrating in 80% (MR 68%). Acidosis, defined as a pH <7.2 (MR 81%) or a base deficit >10 (MR 77%), was a predictor of death (P < .0001). Patients resuscitated directly in the operating room had a significantly lower MR (40%) than those resuscitated in the trauma room (MR 78%; P < .02). The lack of retroperitoneal tamponade (P < .02), the presence of associated intra-abdominal injuries (P < .001), and the location of aortic injury at the subdiaphragmatic (18%; MR 90%) or suprarenal location (37%; MR 71%; P < .005) at exploration resulted in significantly higher patient mortality. Surgical management consisted of primary repair in 26, end-to-end repair in 1, interposition graft in 8, or patch in 1. Resuscitative thoracotomy was performed in 27 patients (45%), with an overall MR of 92%.
CONCLUSION: Despite advances in fluid resuscitation, operative strategy, and transport during the past 20 years, the mortality of traumatic injury to the abdominal aorta remains high. Shock, acidosis, suprarenal aortic injury, and a lack of retroperitoneal tamponade all independently contribute to mortality and should raise the suspicion for a potentially lethal aortic injury in a severely injured patient. Rapid identification and resuscitation in the operating room may therefore be the only factors to improve current survival rates in such devastating injuries.