Punctured

A 28-year-old male bicyclist is brought to the emergency department about 30 minutes after he was hit by a car.

In the field, he was found to be unconscious with a Glasgow coma score (GCS) of 6, and subsequently intubated. He also had an open injury of the right leg. The affected limb was immobilized with a posterior splint.

Focused assessment with sonography for trauma (FAST) is negative for fluid in all four windows, while chest and pelvic x-rays are negative for acute bony injuries. However, x-rays of the right lower extremity reveal a tibia-fibula fracture.

Select Relevant Investigations
Contrast CT Chest + Abdomen

Performed

There is an injury to the proximal descending aorta, with intimal flap formation, and an associated pseudoaneurysm.
CT Angiogram

Performed

There is an aortic intimal flap with a pseudoaneurysm 2 cm distal to the take-off of the left subclavian artery from the aortic arch, with disruption of the medial wall of the descending thoracic aorta.
Coagulation studies

Performed

PT: 12.7 sec (11-13)
INR: 1.0 (0.9-1.1)
APTT: 31.7 s (30-40)
Transesophageal Echocardiogram

Performed

You realize that performing a transesophageal echocardiogram would waste valuable time.

Select Relevant Management
Aggressive IV fluid therapy
IV Nicardipine
Admission to the ICU
Endovascular aneurysm repair