transcript
- Slide 1
- BLUNT THORACIC AORTIC RUPTURE MECHANISM 4. KEY NOTE ::
EMERGENCY SURGERY: VASCULAR EMERGENCIES SUNDAY, MAY 13, 2012 8:30
AM-10:00 AM 03-SYDNEY 13TH ECTES BASLE Gottfried Treviranus, M.D.
Psychiatrist, Berne 1991-93 Swiss- 2000 Light Safety Vehicle group
(pre-smart) at Uni/ETH Z rich (K ser, Niederer, Walz). 1981-1991
Paediatric, General, Spine Surgery, and T&O sternal
rotation-thoracic buckling extends "manubrial pinch" SIDE #0011 ;
THORACIC AORTIC RUPTURE: a new sternal rotation-thoracic buckling
theory extends "manubrial pinch" to explain autopsies after SIDE
IMPACT. Use in early care and FE- safety engineering. www.bio-me.ch
user: ectes password: bs
- Slide 2
- BLUNT TRAUMATIC AORTIC RUPTURE Traffic Inj. Prev. 2008
Jun;9(2):153-61 LAMIH Universit de Valenciennes et du HC Problem:
Problem: RTA- + 2. 4 % in SIDE impacts >>1. 1 % FRONTAL
(explained 1990 by pinch) b-TAR Relevance: killed RTA-occupants: (1
st :) 2/3 TBI (2 nd =)1:8 ( 2 ) b-TAR 1:6 survive killed
pedestrians (2 nd =) ~ 1:7 killed pedestrians 1:10 survive 1.2 % of
occupants 21.4 % of fatalities (+) Problem: Problem: RTA- + 2. 4 %
in SIDE impacts >>1. 1 % FRONTAL (explained 1990 by pinch)
b-TAR Relevance: killed RTA-occupants: (1 st :) 2/3 TBI (2 nd =)1:8
( 2 ) b-TAR 1:6 survive killed pedestrians (2 nd =) ~ 1:7 killed
pedestrians 1:10 survive 1.2 % of occupants 21.4 % of fatalities
(+) CCIS (UK) (n= 5074; 1998-2006) ON SITE RECOGNITION contusion
& fracture pattern, causal crash environment >3 rib# Trauma
centre 1.8 OR aorta SAFETY DESIGN sensors, airbags, padding, less
compartment intrusion.
- Slide 3
- classic Katyal`97 ? RTA : classic ISTHMUS ascend 56% classic
44% ascend ZURICH FORENSIC Institute THORACIC# PATTERN classic the
sketch THORACIC # PATTERN ISTHMUS overly bent OR straight RIB
#
- Slide 4
- # i # e # i # e # e protection Late SERIAL fracture site moves
closer to STERNUM The reverse happens # e X
- Slide 5
- A low-tech TOOLBOX 4 blunt TAR ANALYSIS In not-too-flail chests
the 6df-movements of the STERNUM suffice to determine, whats going
on because In not-too-flail chests the STERNUM despite interposed
tissue - comes mechanically down to the VERTEBRAL COLUMN else there
will be NO bluntTAR Buckling, but unsound STERNAL rotation of
descent, around sagittal, and vertical axes Proposed mechanism for
e.g. high R side impact
- Slide 6
- 3# : 2# 7 ribs # GE Voigt 1968 1 st rib ROLLS OVER COLUMN
MANUBRIO-STERNUM ROLLS OVER COLUMN 1:: 1:: bluntTAR is caused via
non-too-flail chests the handle comes down as far as the vertebral
COLUMN permits. 2:: 2:: the handle will balance on the vertebral
COLUMN 3:: 3:: which side it will cut across the aorta below its
arch depends on R/L displacement & sternal area integrity /
rotations, determined by OVERALL serial fracture buckling 4:: 4::
the COLUMN barrier funnels the many impacts to monotonous winding
roller cuts (asc. or classic). # # ## Side IMPACT causes buckling
SERIAL fractures # - # - # - # 6 ribs #
- Slide 7
- 1 st rational theory ever, BUT thought to be valid only for
FRONTAL cases.... Case Western Univ. Cleveland OH osseouspinch 1 st
RIB-STERNAL HANDLE isthmus the vertebral COLUMN Crass et al. in
1990
- Slide 8
- pinch: aorta into the ROLLERS by winding VERTEBRA manubrium
LEFT IMPACT RIGHT IMPACT propelled blood & wall matrix FRONTAL
IMPACT Transection relativemotion relativemotion
- Slide 9
- 2007 A pressure spike alone is unlikely to be the primary cause
of the peri-isthmus injury but may well be a contributory
prerequisite. R. Pearson R et al. (2007) Div. of O & Accident
Surgery, Queens Medical Centre, Nottingham, UK The same group from
Nottingham had used FINITE ELEMENTS in 2004 Why didn't they
consider the osseous pinch a closed bluntly sharp injury? What went
wrong? was the initial concept faulty? A pressure spike alone is
unlikely to be the primary cause of the peri-isthmus injury but may
well be a contributory prerequisite. R. Pearson R et al. (2007)
Div. of O & Accident Surgery, Queens Medical Centre,
Nottingham, UK The same group from Nottingham had used FINITE
ELEMENTS in 2004 Why didn't they consider the osseous pinch a
closed bluntly sharp injury? What went wrong? was the initial
concept faulty? Blunt TAR in 21 st Century ?.-( William Clifford
Roberts, MD Baylor Heart and Vascular Institute, Dallas, Texas 2006
1990 2009 1973-2006 2012 Benjamin-MM Proc (Bayl Univ Med Cent)
2012;25(2):123
- Slide 10
- shovel, water hammer: well & alive! Siegel JH et al.
Analysis (..) Lateral Impact Aortic Isthmus Disruption in Real-Life
(..) Using a Computer-Based Finite Element (..) Model: With
Simulation of Prevention (..) J Trauma. 2010; 68: 137595 :: Siegel
JH et al. Computer simulation and validation of the Archimedic
Lever hypothesis (..) in a case of lateral impactJ Trauma. 2006;
60:1072 Schmocker JD et a. (120 PSI pressure jet on porcine aorta
in vivo) J Trauma. 2008;64:923931 2006 / 2010 2008 torque pressure
pulse Engineering: tubes under pressure buckle laterally, unless
certain wall properties make them straighten out Galileo 1638
- Slide 11
- Why is it all so hard?Why is it all so hard? frightening
injury: most bleed to death instantly frightening mechanism:
thoracic wall easily reaches spine w/ hidden or no fractures
(Revenstorf 1903) puzzling true and apparent failures of theories
due to lack of basic mechanics & positivistic (unpreposessed)
approach to OVERALL IMPACT experiments which feed supercomputing
models with scarce normative data complicated mechanical injury
pathways which converge into two simple common final pathways:
funnel BLUNT TRAUMATIC AORTIC RUPTURE www.bio-me.ch user: ectes
password: bs Safety has limits!
- Slide 12
- THE LITERATURE AFTER 1900 After 1900 modern traffic caused more
and more blunt TAR: which were separated from degenerations of the
aortic wall. From its onset the literature was highly speculative,
ignorant even of the falling law and correct Laplacian wall tension
unable to show, how the robust aorta could be injured (or pulled)
via tractions from other tissues. After 1900 modern traffic caused
more and more blunt TAR: which were separated from degenerations of
the aortic wall. From its onset the literature was highly
speculative, ignorant even of the falling law and correct Laplacian
wall tension unable to show, how the robust aorta could be injured
(or pulled) via tractions from other tissues. falling law
- Slide 13
- THE LITERATURE AFTER 1900 Revenstorf (1905) underscored the
Parallel Thoraco-Vertebral Joint movement but also torsions of the
aortic root. Oppenheim (1980) used 2 atm. water to blast closed
aortic specimen. Only the surgeons Beitzke and Berblinger (1916)
referred to the obvious pinching mechanisms in injured heart &
aorta. Revenstorf (1905) underscored the Parallel Thoraco-Vertebral
Joint movement but also torsions of the aortic root. Oppenheim
(1980) used 2 atm. water to blast closed aortic specimen. Only the
surgeons Beitzke and Berblinger (1916) referred to the obvious
pinching mechanisms in injured heart & aorta.
- Slide 14
- THE LITERATURE AFTER 1945 1947 J. Stapp founds Automotive Crash
research at Columbia Univ. New York Tannenbaum promotes
deceleration of thoracic contents theory of aircraft victims w/ TAR
(proposed by G.H. Hass in 1944) w/o any proof. 1947 J. Stapp founds
Automotive Crash research at Columbia Univ. New York Tannenbaum
promotes deceleration of thoracic contents theory of aircraft
victims w/ TAR (proposed by G.H. Hass in 1944) w/o any proof.
- Slide 15
- THE LITERATURE AFTER 1955 1955 - Swiss-U.S. cardio-surgeon
Zehnder insists on disruptive bending-burst of the aortic arch as a
common mechanism of every TAR usually by traction from the
onward-falling heart (Rssle 1911) w / path-length= max.