Triage Children with known or suspected great vessel injury should be evaluated immediately, mobilizing the highest level of trauma care available Preparations for both radiologic evaluation and surgical intervention should begin as soon as the injury is suspected, as even the stable patient may deteriorate very rapidly Clinical Assessment Children are usually symptomatic from associated injuries, and great vessel injuries can easily be missed Clinical signs may include difference in pulse between the arms or arms and legs, thoracic ecchymosis, thoracic and back tenderness, paraplegia, and anuria In patients with more severe injuries, hypotension or excessive bleeding from a chest tube may be seen Patients with paraplegia and back pain may be initially diagnosed with a spinal cord injury Unfortunately, 50% of patients with aortic injuries may have no signs pertaining directly to that injury Management Early diagnosis is imperative in patients with aortic or other great vessel injuries Morbidity and mortality increase threefold if operative intervention is delayed more than 12 hours CXR is usually the initial study performed Findings may include a widened mediastinum, blurred aortic knob, pleural cap, or tracheal or nasogastric tube deviation ( Fig 115.8 ) While a normal CXR has been reported to have a 98% negative predictive value in excluding thoracic aortic tear, specificity of an abnormal radiograph is poor and, given sufficient clinical suspicion, further imaging is required to make the diagnosis Multidetector CT angiography has largely replaced echocardiography and aortography as the imaging modality of choice in diagnosing aortic injury, though its test characteristics in children are unknown CT angiography should not be performed routinely on children with thoracic trauma; its use should be limited to those with high suspicion for injury to the aorta and great vessels based on clinical presentation or results of CXR For the stable patient with an equivocal CT or who requires further delineation of the injury, aortography may be an appropriate follow-up study ( Fig 115.9 ) Treatment of great vessel injuries varies based on degree and location of injury and stability of the patient Therapeutic options include fluid resuscitation and use of beta blockers in hemodynamically stable patients, blood transfusion, and open or endovascular repair