study varies based on clinical user. The trans esophageal echo relies on placement an ultrasound probe into the patient's esophagus in order to get an ultrasound of the heart. If esophageal injury is expected, the patient has a facial injury, or if the patient has difficulty maintaining their away then the trans esophageal echo is contraindicated. Treatment The first line treatment for patients with thoracic aortic injury is maintaining the patient's airway with intubation and treating secondary injuries such as a hemothorax. After ensuring the patient has a patent airway and other life-threatening injuries are treated then treatment for the aortic injury can be started. Due to the constant risk of sudden rupture or exsanguination urgent treatment is necessary. A patient can either undergo endovascular repair or surgical repair. Endovascular repair is the current gold standard due to increased success rates and lower complications. Patients that are able to undergo endovascular repair without contraindications should proceed with it. Repair should be delayed if there is life-threatening intra-abdominal or intracranial bleeding or if the patient is at risk for infection. Endovascular Repair Endovascular repair is done by first gaining vascular access usually through the femoral artery. A catheter is inserted to the point of injury and a luminal stent is deployed. Blood is then able to be pumped through the stent and prevent the aortic wall from rupturing. Open Surgical Repair Surgical repair is done by way of a thoracotomy or opening of the chest wall. From this point multiple methods can be used, but the most successful methods enable distal perfusion to prevent ischemia. When the surgery is performed a constant check of blood flow to the parts of the body away from the injury should be monitored to know if oxygenation is occurring. Medical Management While waiting for surgery careful regulation of blood pressure and heart rate is necessary. Systolic blood pressure should be maintained between 100 and 120 mmHg allowing for perfusion distal to the injury but decreasing the risk of rupture while the heart rate should be kept under 100 beats per minute. Esmolol is first choice to maintain blood pressure and heart rate due to its short time of action, but if the blood pressure is not within range adding nitroprusside sodium can be added as a second agent. The treatment is similar to what is done for aortic dissections. If the patient has minimal aortic