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Sir,—Those who manage patients with possible cardiac and aortic injury may well be encouraged to consider relying on investigation by means of transoesophageal echocardiography in the light of the recent editorial by Treasure.1However, Banning and Pillai2 were right to conclude that no single imaging technique is ideal for the investigation of possible aortic injury in survivors of major trauma. Disruption of major branches of the aorta, single or multiple, and not necessarily in association with aortic laceration, can occur as a result of non-penetrating injury3-5 and may be underdiagnosed.6 Investigation of patients who are suspected of having sustained severe injury as a result of acceleration/deceleration forces or crush injury should, therefore, routinely include examination of the major branches of the aorta by other methods such as computed tomography, magnetic resonance imaging or aortography.
This letter was shown to the author, who replies as follows:
Dr Davies’s case report was of a cyclist who was run over by a reversing car, a low velocity crushing injury resulting in avulsion of a carotid artery. One imagines that theLancet published it because it is was a very unusual story.1-1 My editorial1-2 was written to accompany a double case report of two injured teenagers rescued from the same car after a high speed collision.1-3 This history is associated with a characteristic and reproducible pattern of aortic injury, well known to surgeons,1-4 and our intention as editors was to summarise the published facts and figures of investigation in that context. I doubt if my cautiously written piece would wrongly encourage people to “rely on investigation by transoesophageal echocardiography”. I certainly hope not. Prompted by Dr Davies’s letter, I discovered that, like many other hospitals, his has no magnetic resonance imaging, no spiral computed tomography, and no angiography facilities. Those were the circumstances that faced Absolom et al and which led to them reporting their success in advancing the diagnosis by transoesophageal echocardiography.1-3 Every clinical problem has to be managed in context and, in the case of suspected aortic trauma, that includes how stable the patient is, what other injuries are present, how suspicious you are of the diagnosis, your knowledge and experience, and the facilities at your disposal.