SUMMARYThis communication reports a case of traumatic rupture of the thoracic aorta. T h e literature on this subject is reviewed, the problem of diagnosis is discussed, and the importance of acute hypertension as a diagnostic sign is stressed. In view of the fact that the hypertension in the case reported here occurred in the presence of good femoral pulses and persisted after operation, the cause of the hypertension may not be simply an acute coarctation syndrome but may be due to damage to the cardiac plexuses around the site of rupture. It also emphasizes the importance of not rewarming severely traumatized hypothermic patients until facilities are available to replace blood-loss.
CASE REPORTA 19-year-old university student was buried under a pile of rocks after falling about 9 m. while pot-holing in Derbyshire.During his rescue from the caves the general practitioner in charge of the operation decided against using a rubber protection suit, being in favour of getting the patient out of the cave as quickly as possible.On admission to the Sheffield Royal Infirmary Casualty Department 8 hours after the fall the patient was chilled, shivering, and had peripheral cyanosis. He was covered with minor lacerations and abrasions, but there was no external evidence of severe injury. On examination his pulse was 120 per minute, his blood-pressure was 90j40, and his rectal temperature was 32.2' C. He was tender on compression of the chest and had minimal physical signs in the left chest. He was tender in both hypochondria, and bowel-sounds were absent. Radiographs showed a crack fracture of the ilium on both sides and avulsion of the transverse process of the third lumbar vertebra.The patient was transferred to the ward and was slowly warmed with blankets. Six hours after admission his temperature was 38.4" C., his blood-pressure had fallen to 8o/so, and his pulse was IZO per minute. At this time he was becoming dyspnoeic and was developing physical signs of a left haemopneumothorax, which a chest radiograph confirmed. After transfusion with 400 ml. of plasma, his blood-pressure rose to 110/60 and he was transferred to the operating theatre. A left-sided anterolateral chest drain was inserted and a left paramedian abdominal incision was made. A ruptured spleen was removed and a ruptured liver was repaired.Postoperatively the patient was at first greatly improved. However, 3 days after the operation he had developed a collapsing pulse with a blood-pressure of 200-190/60. He had also developed a systolic murmur over the left scapula region, and a chest radiograph showed widening of the mediastinum and cardiomegaly. There were good femoral pulses on both sides.Four days after admission the heart continued to increase in size, the systolic murmur was louder and could be heard in the lumbar region, and the left hypochondrium and the blood-pressure continued to be raised. The blood-pressure varied from recording to recording, involving mainly the systolic reading with a correspondingly high pulse-pressure. An aortogram was th...
