• Patients with blunt trauma may have their cervical spines cleared clinically if they meet the following criteria: 

• Not clinically intoxicated (reliable physical exam) 

• Awake and alert with a GCS of 15 

• No neck pain or tenderness on exam or motion of neck 

• No neurological findings (motor or sensory) 

• No distracting pain 

• If the above criteria cannot be met, then the C-spine must be cleared with a CT C-spine. If the CT C-spine is negative for fracture, then the C-spine should be clinically reevaluated. If the patient is then clinically sober with a normal GCS and no longer has neck pain or tenderness, the C-spine can be cleared clinically. 

• All patients with any neurologic symptom consistent with C-spine injury (paresthesia or weakness in the upper extremities) should have a STAT MRI C-spine. 

• If the patient continues to have neck pain or tenderness AND the patient is clinically sober with a normal GCS AND has no neurologic symptoms consistent with C-spine injury: 

• The collar may be cleared if an attending radiologist dictates a FINAL negative read on the high quality CT C-spine. 

• If an attending read will not be completed (e.g., overnight) before the patient is otherwise ready to be discharged, the ligaments can be cleared with a flexion / extension x-ray. 

• The flexion / extension x-ray must image the area of pain or tenderness and have adequate flexion and extension (15 degrees each direction).  

• If a patient has persistent midline C-spine pain with a negative CT C-spine +/- negative flex / ex (with adequate visualization of tender area and flexion) then the C-spine is cleared. The patient does not require a Miami J collar / neurosurgery follow-up.  

• If a flexion / extension x-ray is inadequate or cannot be performed, then an MRI of C-spine is the final method for clearing a C-spine in an awake patient. 

• If a C-spine is unable to be cleared in an obtunded patient, then a high quality CT C-spine is obtained. If an attending radiologist reads the CT as normal, and there are no focal neurological deficits (symmetric upper and lower extremity strength),  the cervical collar may be removed. Any abnormality on the CT C-spine should prompt a neurosurgery consult and a cervical spine MRI. 

Patient criteria that warrant BCVI screening: 

• Cervical bruit in age <50 

• Expanding cervical hematoma 

• Focal neurologic deficit 

• Neuro exam incongruous with head CT findings 

• Le Fort 2-3 fractures 

• Bilateral mandible fx with any displacement 

• Basilar skull fracture (petrous, sphenoid, clivus, occipital condyle) 

• GCS < 6 

• C-spine fx with subluxation or ligamentous injury at any level, fracture near vertebral canal 

• Any C1-3 fracture 

• Hanging with anoxic injury (any LOC) 

• Seatbelt sign with swelling, pain, or AMS 

Additional specific indicators of high-energy mechanism that warrant BCVI screening: 

• TBI (GCS < 15) with thoracic injury 

• Upper rib fractures (1-3) 

• Scalp degloving 

• Thoracic vascular injury 

CT Head indicated: 

• Loss of consciousness (LOC) 

• Amnestic to event 

• GCS<15 

• Patient on anticoagulant or antithrombotic 

• Age >65 

• Sign of basilar skull fracture 

• Concern for skull fracture 

▪ If CT head negative AND GCS 15 AND patient not intoxicated AND not on  anticoagulant or antithrombotic: 

• Discharge home – no need for family observation 

• Cermak patients can be returned to Cermak 

▪ If CT head negative AND patient is on anticoagulant or antithrombotic: • Discharge home WITH family to watch for 23hrs if INR <3 

• If INR >3, keep in OBS for 23hrs 

▪ To discharge home, patient must be neurologically intact, not intoxicated, and able  to self ambulate. All others should be admitted for 23 hour observation. 

▪ Loss of consciousness that is the result of a syncopal episode should get a CT  head, an EKG, Troponin, orthostatic blood pressure, and a medicine consult for a 

syncope workup (see nonsurgical admit guideline), in addition to the remainder of  their symptom-based trauma workup.

Introduction: 

Initial workup should be focused upon accurate anatomic identification and categorization of the aortic injury and assessment of associated injuries. This information will be evaluated jointly by the trauma team and the vascular team to establish treatment priorities and formulate therapeutic plans as outlined below. 

Priorities: 

1. Identification of patients with high speed deceleration injuries as warranting CT Scans with IV Contrast of the Chest. 

2. Management of patient’s hemodynamics so as to prevent increased shear stress on the aortic wall and extension of rupture. 

3. Identifying patients who have hypotension and require urgent thoracotomy. 

Diagnosis: 

• Patients with severe blunt chest trauma, especially those with deceleration-type injuries, will be evaluated using CT of the chest with IV contrast.  

• Blunt aortic injury risk factors: 

• Accelerating / decelerating injuries > 30MPH, falls >30feet, or sudden compression of chest (i.e., car falling off jack) 

• Physical exam findings – abrasions or tenderness of chest wall 

• Abnormalities on CXR 

• If a patient has an appropriate mechanism (risk factor 1) PLUS one of the other factors – imaging or physical exam findings, then the patient should have a CT of the chest with “arch protocol” to evaluate their aorta. 

• If the CT arch is abnormal, cardiac / vascular surgery is consulted. 

Grading of Injuries: 

• Injuries will be graded according to the current Society of Vascular Surgery (SVS) guidelines. 

• Grade 1 – Intimal tear (normal external contour of aorta) 

• Grade 2 – Intra-mural hematoma 

• Grade 3 – Pseudoaneurysm 

• Grade 4 – Pseudoaneurysm with rupture 

Initial Medical Management: 

• All patients with aortic injuries should have active control of blood pressure and heart rate with β blockade to minimize wall shear stress and decrease potential for expansion or rupture. 

• Therapeutic targets are: SBP < 120, MAP < 80, and pulse < 90. 

• If SBP >120 or pulse > 90, start Esmolol 500 μg/kg slow bolus over 30 seconds, if BP remains > 120 repeat 500 μg/kg slow bolus over 30 seconds. Use caution, titrate carefully to avoid hypotension (SBP < 80 or MAP < 60) 

• Start infusion at 50 μg/kg/min 

• Titrate drip to achieve target SBP, be cautious to avoid hypotension (SBP<80, MAP< 60) especially in patients with potential brain injury 

• Stable patients without need for ICU admission may receive oral beta-blocker 

Treatment: 

• Grade 1 injuries are generally managed medically with repeat imaging as indicated. 

• Grade 2 injuries may be managed medically or by TEVAR. Therapeutic plans should be made jointly. 

• Grade 3 injuries without high-risk features should undergo TEVAR within 24 hours after admission. 

• Specific therapeutic plans, including order and timing of interventions, should be established jointly after consideration of all associated injuries, most importantly the presence of severe brain injury 

• Grade 3 injuries with high-risk features should undergo emergency TEVAR. 

• High risk features include: 

• Aortic arch hematoma 

• Ascending aortic, aortic arch, or great vessel involvement 

• Mediastinal hematoma causing mass effect 

• Posterior mediastinal hematoma > 10 mm 

• Lesion to normal aortic diameter ratio > 1.4 

• Pseudocoarctation of the aorta 

• Large left hemothorax 

• Grade 4 injuries should undergo emergency TEVAR. These patients have substantial risk of decompensation and death. 

Medical Management: 

• Anti-platelet therapy: 

• Given for all grade injuries and for medically and surgically treated patients as allowed by concomitant injuries. 

• Dose: 81 mg per day. 

• For patients treated with TEVAR they will take 81 mg for 30 days post-op 

• For patients treated medically they will take 81 mg until injury resolves on imaging 

• Blood pressure and heart rate targets: 

• Non-operative management: transition esmolol drip to oral beta blockers to goal SBP<120 mmHg and pulse <90. 

• After repair: no blood pressure management required after endovascular coverage of the injury 

• For patients treated medically, impulse control goals with oral beta blockers will continue until injury resolution seen on imaging 

Follow up: 

• Repeat imaging is not needed inpatient after TEVAR 

• Repeat imaging inpatient for patients treated medically will be done on select patients as decided by the vascular team 

• All patients with BTAI should have follow-up CTA scheduled at about 6 weeks post injury 

• All patients with BTAI should have appropriate follow-up with vascular surgery. 

Patients with blunt trauma to the abdomen should have an evaluation for intra-abdominal injuries. Methods of evaluation are: 

Stable Patient 

• CT abdomen / pelvis 

• Evaluation for solid organ injury and spine 

Unstable Patient 

• FAST 

• For use in unstable blunt abdominal patients to identify cavity with hemorrhage 

• DPL 

• Useful to identify which cavity is the source of bleeding 

• Aspirate is most useful in unstable patients 

• If full lavage is done: 

• RBC > 100,000 is positive 

If patient is stable and refuses imaging, serial abdominal examination can be offered 

• Must be done frequently and by the same examiner 

• Only in stable patients 

• If the patient is getting a CT arch or a CT abdomen / pelvis, the spine can be reconstructed from these images. 

• A non-contrast CT chest / abdomen with spine reconstruction is less radiation than a dedicated spine CT and may allow for more information such as occult rib fractures or pneumothorax. 

• Consider non-contrast chest and / or abdomen to reconstruct the spine if unable to clear clinically. 

When to consult neurosurgery: 

Cervical spine – all fractures 

Thoracic spine – any fracture except isolated transverse process 

Lumbar spine – any fracture except isolated transverse process