Elsevier

The Journal of Emergency Medicine

Volume 8, Issue 4, July–August 1990, Pages 467-476
The Journal of Emergency Medicine

Emergency medicine in review
The normal mediastinum in blunt traumatic rupture of the thoracic aorta and brachiocephalic arteries

https://doi.org/10.1016/0736-4679(90)90178-XGet rights and content

Abstract

In a review of 52 articles, published between 1953 and 1989, 656 patients with blunt traumatic rupture of the thoracic aorta or brachiocephalic arteries were identified. Of these, 608 (92.7%) had an abnormal mediastinum on initial chest radiographs obtained in the emergency department, thus allowing early detection of the vascular injury. Unfortunately, 48 (7.3%) of these patients had a normal mediastinum on their initial chest radiographs. This appears to occur when the traumatic pseudoaneurysm is not accompanied by associated mediastinal hemorrhage or hematoma formation, and the pseudoaneurysm is either small or is situated in such a way that it does not alter the mediastinal contour. The use of accessory clinical and radiographic signs to indicate the need for aortography has been shown to be of very low yield, but would have allowed the early detection of an additional 5.6% of the reported cases. Performing aortography solely on the basis of a history of major decelerating blunt trauma to the thorax remains the only way, in the acute emergency department setting, to detect the 1.7% of patients with aortic or brachiocephalic arterial rupture who have no mediastinal abnormality or accessory clinical or radiographic signs of vascular injury. There is evidence from the literature, however, to suggest that the evaluation of serial chest radiographs obtained at close intervals for the first month following trauma for the development of mediastinal abnormality or large hemothorax is an acceptable alternative to the routine performance of aortography in those blunt chest trauma victims with no clinical or radiographic suspicion of vascular injury.

References (72)

  • J.T. Sturm et al.

    Chest roentgenographic findings in 26 patients with traumatic rupture of the thoracic aorta

    Ann Emerg Med.

    (1983)
  • J.T. Sturm et al.

    The management of subclavian artery injuries following blunt thoracic trauma

    Ann Thorac Surg.

    (1984)
  • R.T. Kubota et al.

    Evaluation of traumatic rupture of descending aorta by aortography and computed tomography: case report with follow-up

    CT: J Computed Tomogr.

    (1985)
  • K.E. Marnocha et al.

    Blunt chest trauma and suspected aortic rupture: reliability of chest radiographic findings

    Ann Emerg Med.

    (1985)
  • J.H. Woodring et al.

    The potential effects of radiographic criteria to exclude aortography in patients with blunt chest trauma

    J Thorac Cardiovasc Surg.

    (1989)
  • C.W. Schwab et al.

    Aortic injury: comparison of supine and upright portable chest films to evaluate the widened mediastinum

    Ann Emerg Med.

    (1984)
  • R.E. Burney et al.

    Chest roentgenograms in diagnosis of traumatic rupture of the aorta: observer variation in interpretation

    Chest

    (1984)
  • R.D. White et al.

    Noninvasive evaluation of suspected thoracic aortic disease by contrast-enhanced computed tomography

    Am J Cardiol.

    (1986)
  • L.F. Parmley et al.

    Nonpenetrating traumatic injury of the aorta

    Circulation

    (1953)
  • M.A. Zehnder

    Delayed post-traumatic rupture of the aorta in a young healthy individual after closed injury mechanical-etiological considerations

    Angiology

    (1956)
  • R.J. Stoney et al.

    Arch Surg.

    (1964)
  • R.D. Fisher et al.

    Subclavian artery laceration resulting from fractured first rib

    J Trauma.

    (1966)
  • F. Sandor

    Incidence and significance of traumatic mediastinal haematoma

    Thorax.

    (1967)
  • T.A. Freed et al.

    Arteriographic demonstration of laceration of great vessels secondary to blunt chest trauma

    Radiology

    (1968)
  • I.E. Langbein et al.

    Traumatic rupture of the aorta

    Australas Radiol.

    (1968)
  • E.O. Lipchik et al.

    Acute traumatic rupture of the thoracic aorta

    AIR

    (1968)
  • T.T. Flaherty et al.

    Nonpenetrating injuries to the throacic aorta

    Radiology

    (1969)
  • E.R. Davis et al.

    Aortography in the investigation of traumatic mediastinal haematoma

    Clin Radiol.

    (1970)
  • J.L. Eller et al.

    Avulsion of the innominate artery from the aortic arch an evaluation of roentgenographic findings

    Radiology

    (1970)
  • M.M. Kirsh et al.

    Roentgenographic evaluation of traumatic rupture of the aorta

    Surg Gynecol Obstet.

    (1970)
  • H.H.M. DeBoer et al.

    Traumatic aneurysm of the thoracic aorta

    Arch Chir Neerl.

    (1971)
  • M.J. O'Sullivan et al.

    Posttraumatic thoracic aortic aneurysm: recognition and treatment

    Arch Surg.

    (1972)
  • R.F. Wilson et al.

    Acute mediastinal widening following blunt chest trauma: critical decisions

    Arch Surg.

    (1972)
  • M.M. Kirsh et al.

    The treatment of acute traumatic rupture of the aorta: a 10-year experience

    Ann Surg.

    (1976)
  • R.J. Ayella et al.

    Ruptured thoracic aorta due to blunt trauma

    J Trauma.

    (1977)
  • R.M. Faraci et al.

    Dissecting hematoma of the aorta secondary to blunt chest trauma

    Radiology

    (1977)
  • Cited by (106)

    • Blunt Thoracic Aortic Injury

      2021, Rich’s Vascular Trauma
    • Blunt Trauma: What Is Behind the Widened Mediastinum on Chest X-Ray (CXR)?

      2019, Journal of Surgical Research
      Citation Excerpt :

      This applies especially in patients with a high-speed decelerating blunt injury.2 Previous publications have described a variable sensitivity for detecting AIs after blunt chest trauma, ranging from 41% to 93%.3-6 However, chest X-rays (CXRs) are still used in the trauma resuscitation bay because of their accessibility, portability, low radiation burden, and prompt results.

    • The utility of chest X-ray as a screening tool for blunt thoracic aortic injury

      2016, Injury
      Citation Excerpt :

      Non-mediastinal abnormalities are less sensitive and specific indicators of BTAI and include a right-shifted trachea, pulmonary contusion, and left apical cap [8]. Previous studies have demonstrated overall sensitivities of CXR for BTAI ranging from 56% to 93% [9–11]. These studies included either non-mediastinal findings or only a single mediastinal finding as part of their sensitivity calculations.

    • Traumatic aortic dissection presenting with respiratory arrest

      2015, African Journal of Emergency Medicine
    • Aortic dissection associated with blunt chest trauma diagnosed by elevated D-dimer

      2015, International Journal of Surgery Case Reports
      Citation Excerpt :

      The use of D-dimer to diagnose acute traumatic aortic injury in patients with blunt chest trauma, to our knowledge, has not been studied or described. The classic teaching that aortic injury secondary to blunt trauma is associated with a major mechanism, significant physical findings, and abnormalities of chest radiography is not universally true [5,9,10,13]. In this patient who presented with only mild symptoms temporally associated with a traumatic event, aortic dissection was discovered in pursuit of an unrelated diagnosis using a D-dimer test.

    View all citing articles on Scopus
    View full text