Little attention has been given to the sequential assessment and management of a cohort of patients with potential aortic disruption manifested by a widened mediastinum. These patients often require diagnostic peritoneal lavage (DPL), cranial computed tomography (CCT) scan, thoracic aortography, and multiple operations. We surveyed 408 patients with a widened mediastinum who underwent aortography from 1981 to 1989 to determine priorities of management. Multisystem injuries were common with 278 (68%) and 72 (18%) of patients requiring DPL and celiotomy, respectively. Central nervous system (CNS) injury occurred in 276 (68%) patients, and orthopedic injuries were present in 162 (40%). There were 35 thoracic aortic injuries and 17 branch injuries with 15 deaths (11 aortic, 4 branch). Mortality primarily was attributed to hemorrhage, neurologic injuries, and multisystem organ failure. We evaluated the sequence of diagnostic and therapeutic interventions to determine possible sequence errors and 98% of patients had no errors identified. Based on this experience, we have formulated a management protocol for evaluation of patients with multiple injuries and a widened mediastinum.