![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Blunt chest trauma - suspected aortic injury.

#### BIBLIOGRAPHIC SOURCE(S)

Holtzman SR, Bettmann MA, Casciani T, Gomes AS, Grollman JH, Polak JF,
Sacks D, Stanford W, Jaff M, Moneta GL, Expert Panel on Cardiovascular
Imaging. Blunt chest trauma\--suspected aortic injury. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 5
p. \[35 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous published version: Kelley MJ, Bettmann MA, Boxt
LM, Gomes AS, Grollman J, Henkin RE, Higgins CB, Needleman L,
Pagan-Marin H, Polak JF, Stanford W. Blunt chest trauma\--suspected
aortic injury. American College of Radiology. ACR Appropriateness
Criteria. Radiology 2000 Jun;215(Suppl):35-9. \[29 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Blunt chest trauma, suspected aortic injury

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Cardiology\
Emergency Medicine\
Internal Medicine\
Radiology\
Surgery

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
blunt chest trauma-suspected aortic injury

#### TARGET POPULATION

Patients with blunt chest trauma, suspected aortic injury

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest

    -   Chest, oblique

    -   Esophagus, esophagram

2.  Invasive (INV), chest, aortography

3.  Chest computed tomography (CT) (helical or multidetector) with
    contrast

4.  Ultrasound (US)

    -   Intravascular

    -   Transesophageal echocardiography (TEE)

    -   Transthoracic echocardiography (TTE)

5.  Magnetic resonance imaging (MRI) of the chest

    -   Without contrast

    -   With contrast

6.  Magnetic resonance angiography (MRA) of the chest

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Blunt Chest Trauma, Suspected Aortic Injury**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                   CXR is part of the initial
                                           screening in blunt chest trauma.
                                           It may increase the probability of
                                           an aortic injury based on findings
                                           suggestive of a mediastinal
                                           hematoma.

  INV, chest,          9                   If there is suspicion of aortic
  aortography                              injury, thoracic aortography, if
                                           rapidly accessible, remains the
                                           gold standard for evaluating the
                                           aorta.

  CT, chest, (helical  8                   CT scanning is a reliable way to
  or multidetector),                       evaluate the mediastinum for
  with contrast                            possible blood. Multislice
                                           scanners can provide exquisite
                                           detail of the aorta and may
                                           replace thoracic aortography as
                                           the \"gold standard.\" The
                                           decision of whether to go directly
                                           to the angio suite or CT after the
                                           initial chest radiograph will
                                           depend on availability and local
                                           expertise.

  US, heart,           6                    
  echocardiography,                        
  transesophageal                          
  (TEE)                                    

  MRI, chest, without  4                   Access to critically ill patients
  contrast                                 poses a problem.

  US, heart,           2                    
  echocardiography,                        
  transthoracic (TTE)                      

  US, intravascular    2                    

  MRI, chest, with     2                    
  contrast                                 

  MRA, chest           2                    

  X-ray, esophagus,    1                    
  esophagram                               

  X-ray, chest,        1                    
  oblique                                  

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

Trauma ranks fifth behind cardiovascular diseases, cancer,
cerebrovascular disease, and chronic lower respiratory diseases as a
cause of death in the United States. There were greater than 100,000
accidental deaths in this country in 2003. Seventy-five percent of the
deaths from blunt trauma are due entirely or in part to chest injuries.
Rupture of the thoracic aorta is a common cause of death following blunt
chest trauma. In more than 80% of cases, rupture is through all three
layers of the aorta, resulting in exsanguination and death at the
accident site. Individuals who survive have maintained the adventitia
intact but are at risk for subsequent complete rupture. For these
near-full-thickness injuries, 30% of initial survivors will die within 6
hours and 20% by 24 hours if the diagnosis is not made and treatment
instituted. With technological advancements, a spectrum of disease is
now being appreciated. Small tears of the intima can now be diagnosed
but the natural history of these \"minimal aortic injuries\" is not yet
known. Imaging may play a role in grading the severity of aortic
injuries to help guide clinical management.

**Pathophysiology**

Traumatic injury of the aorta is thought by most investigators to result
from unequal horizontal shear forces that are applied during high-speed
deceleration to different parts of the thoracic aorta. During rapid
deceleration the mobile ascending and descending portions of the aorta
lag behind the transverse aortic arch, which is relatively fixed by the
brachiocephalic vessels. Injury occurs most commonly at the ligamentum
arteriosum (80%) and less commonly to the ascending aorta. A mechanism
involving compressive forces between anterior and posterior bony
thoracic structures has also been proposed (the \"osseous pinch\").

Because the adventitia remains intact as a barrier to exsanguination in
survivors, the most common pathologic findings are tears of the intima
and media. The hemomediastinum associated with these injuries is
therefore most commonly due to rupture of small arteries and veins in
the mediastinum. Traumatic laceration of the aorta is the most common
lesion seen at autopsy, although survival even from this injury has been
reported. In these rare cases, a pseudoaneurysm is contained by
periaortic tissue. Chronic pseudoaneurysm has been described and may
present many years after the traumatic event.

**Clinical Presentation**

Variation in clinical presentation is the rule with thoracic aortic
injuries. Patients may present in full cardiovascular collapse or
complain of chest pain, midscapular pain, or shortness of breath. Almost
half of patients with aortic disruption have no external signs of chest
trauma. Because of the variable presentation, a high index of suspicion
for traumatic rupture of the aorta must exist for any patient who has
sustained high-speed rapid deceleration.

**Chest Radiograph**

Despite the advent of newer imaging modalities, the chest radiograph
remains the primary screening method for detecting mediastinal
hemorrhage following blunt thoracic trauma. It is included in most
trauma center protocols in the initial evaluation of patients with
polytrauma.

Because of the trauma setting in which chest radiographs of these
patients are obtained, they are usually portable anteroposterior supine
films. This results in a lordotic view with a shortened focal spot-film
distance, magnifying the width of the superior mediastinum and
decreasing resolution. Sitting the patient upright for an
anteroposterior film should result in fewer falsely abnormal films.

Most of the radiograph findings in aortic rupture are related to
mediastinal hemorrhage rather to the aortic injury itself. The most
common chest film finding, widening of the mediastinum, has been defined
as a transverse distance of 8 cm from the left side of the aortic arch
to the right margin of the mediastinum. It must be emphasized that the
vast majority of patients with mediastinal widening do not have aortic
injuries. Angiographically confirmed aortic injury is found in only
10-20% of these patients. Mediastinal widening has a 90% sensitivity but
only a 10% specificity for aortic disruption.

Approximately 7% of patients with aortic rupture have a normal initial
chest radiograph. However, the diagnostic evaluation of patients with
blunt chest trauma now includes chest CT at most facilities. CT has
proven to be very sensitive for the detection of aortic injury. When no
mediastinal hematoma is detected on chest CT, the probability of a
significant aortic injury is very low.

**Thoracic Aortography**

Thoracic aortography is widely accepted as the gold standard for
evaluating patients with suspected aortic injury. The aortogram
establishes the diagnosis, defines the anatomy of the lesion, and,
because approximately 20% of patients have multiple tears, identifies
additional sites of injury. At most institutions, aortography is
performed on patients who have suffered rapid deceleration injury and
who have a widened mediastinum or obscure aortic knob and descending
aorta on a chest radiograph, or who have indirect or direct signs of
aortic injury detected by CT.

Various film sequences have been used, including anteroposterior,
lateral, and oblique projections. It should be emphasized that more than
one projection may be necessary to detect an aortic injury. Because
acutely injured patients are in a hyperdynamic state, high contrast
volumes of 60 to 70 cc rapidly injected are needed. Thoracic aortography
is a safe procedure; the reported mortality rate is 0.03%.

Intra-arterial thoracic digital subtraction angiography is less
expensive, uses less contrast material, and is faster than conventional
aortography. The sensitivity, specificity, and diagnostic accuracy of
digital subtraction angiography are equivalent to those of cut film
arteriography.

**Computed Tomography**

With the increasing availability of spiral CT, the technique is playing
a more prominent role in the assessment of patients with suspected
aortic injury. CT´s strength lies in its ability to distinguish
mediastinal blood from other causes of mediastinal widening detected on
initial chest radiographs, e.g., artifacts of magnification, mediastinal
fat, or anatomic variation. Also, CT may demonstrate the intimal tear or
pseudoaneurysm of the traumatized aorta. Technological advancements with
helical and, more recently, multidetector CT scans have placed CT at the
forefront of evaluating the aorta in cases of blunt thoracic trauma. If
no mediastinal hematoma is detected on CT, the probability of a
significant aortic injury is very low, and aortography is generally not
needed. If direct signs of aortic injury are identified on CT, patients
are sometimes taken to aortography for confirmation or occasionally
taken directly to surgery. Many case series show low but consistent
false positive examinations.

**Magnetic Resonance Imaging of the Thorax**

Although MRI of the thorax can demonstrate acute and subacute
mediastinal hematoma, it currently does not have a role in the initial
evaluation of the critically ill, hemodynamically unstable trauma
patient. MRI, however, has proven to be useful in the evaluation of
chronic traumatic aortic pseudoaneurysms. At the present time, there has
been insufficient experience with other MR techniques to recommend their
use in the trauma setting. Access to critically ill patients in the MR
scanner also poses a potential problem.

**Transesophageal Echocardiography**

TEE is a relatively new technology that has been used in the acute
trauma setting to study both the heart (for contusion) and the thoracic
aorta. It appears to be much more sensitive than transthoracic
echocardiography for detecting cardiac contusions.

TEE is more operator-dependent and more invasive than CT. The procedure
usually requires sedation. In some patients, blind spots created by the
tracheal-bronchial bifurcation may preclude adequate visualization of
portions of the aortic arch. Other blind spots for TEE are the distal
ascending aorta and the aortic arch vessels, sites of traumatic injury
in up to 20% of patients.

Recent studies have reported excellent diagnostic accuracy using TEE for
the recognition of aortic injury. This experience, however, has not been
uniformly positive. Further studies are required before TEE can be
recommended as part of the imaging workup in patients with blunt chest
trauma.

**Intravascular Ultrasound**

The continued development of intravascular ultrasound (IVUS) has offered
an adjunct to standard transfemoral aortography. Although the routine
use of IVUS is neither indicated nor practical, in a few cases it has
been found to be useful in confirming or excluding thoracic aortic
injury when angiographic findings are subtle or uncertain.

**Other Modalities**

There is no support in the literature for the use of esophagrams,
oblique chest films, or intravenous digital subtraction angiography in
the evaluation of suspected aortic injury.

The literature supports the continued use of the plain chest radiograph
as the initial screening exam in the patient who has sustained blunt
chest trauma. In the appropriate clinical setting and with a chest
radiograph demonstrating mediastinal widening or other signs of
mediastinal hemorrhage, thoracic aortography or helical chest CT is
indicated. The possible role of IVUS and TEE in the setting of suspected
thoracic aortic injury awaits further investigation. The overall
accuracy of multidetector CT compared with aortography as the gold
standard remains incompletely defined at this time.

**Abbreviations**

-   CT, computed tomography

-   INV, invasive

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

-   TEE, transesophageal echocardiography

-   TTE, transthoracic echocardiography

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evalutaion of
patients with blunt chest trauma of suspected aortic injury

#### POTENTIAL HARMS

Many case series of computed tomography (CT) show low but consistent
false positive examinations

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Holtzman SR, Bettmann MA, Casciani T, Gomes AS, Grollman JH, Polak JF,
Sacks D, Stanford W, Jaff M, Moneta GL, Expert Panel on Cardiovascular
Imaging. Blunt chest trauma\--suspected aortic injury. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 5
p. \[35 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Cardiovascular
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Names of Panel Members*: Stephen R. Holtzman, MD; Michael A. Bettmann,
MD (*Panel Chair*); Thomas Casciani, MD; Antoinette S. Gomes, MD; Julius
H. Grollman, MD; Joseph F. Polak, MD, MPH; David Sacks, MD; William
Stanford, MD; Michael Jaff, MD; Gregory L. Moneta, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous published version: Kelley MJ, Bettmann MA, Boxt
LM, Gomes AS, Grollman J, Henkin RE, Higgins CB, Needleman L,
Pagan-Marin H, Polak JF, Stanford W. Blunt chest trauma\--suspected
aortic injury. American College of Radiology. ACR Appropriateness
Criteria. Radiology 2000 Jun;215(Suppl):35-9. \[29 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available (in Portable Document Format \[PDF\]) from
the [American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedAorticInjuryDoc6.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 20, 2001. The information
was verified by the guideline developer on March 14, 2001. This summary
was updated by ECRI on March 6, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008