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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

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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.

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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 #

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# i # e # i # e # e protection Late SERIAL fracture site moves closer to STERNUM The reverse happens # e X

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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

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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 #

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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

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pinch: aorta into the ROLLERS by winding VERTEBRA manubrium LEFT IMPACT RIGHT IMPACT propelled blood & wall matrix FRONTAL IMPACT Transection relativemotion relativemotion

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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

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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

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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!

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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

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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.

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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.

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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.