∙ Note that most mediastinal widening which can be seen on X-ray in trauma is venous bleeding. 

AT PRESENTATION

  • -approximately 90% of injuries occur at the isthmus. D/D = ductus diverticulum. and
  • – 3% diaphragm 
  • – 5-10% ascending aorta – these are most common overall, but unfortunately this often proves to be fatal die in the field. Pericardium  wraps over the root, so the patients rupture into a big pericardial tamponade. ∙ CTA EVALUATION 

DIRECT SIGNS OF INJURY

dissection, pseudoaneurysm, transection, extravasation. These go straight to  surgery. 

INDIRECT SIGNS 

  • Hematoma – most of this is venous bleeding. 
  • Blood touching/surrounding aorta ???? should go to angio 
  • Mediastinal hematoma not touching aorta ???? conservative management, likely venous  bleeding. 
  • Sternal fracture 
  • D/D for isthmic pseudoaneurysm = ductus diverticulum (present in 9% of patients). ∙ TX: Very often surgery. Stent grafts are increasingly used – must evaluate the proximal and distal  “landing zones” for adequate footing and potential covering of the supra-aortic artery origins. If you  cover the left subclavian artery, you can (a) watchful wait – often there is plenty of collateral through the  circle of Willis, (b) carotid-subclavian bypass, (c) subclavian-subclavian bypass. 
Internal Mammary Artery injury can occur with chest trauma and result in large hemothorax or hematoma. TX  is coil embolization.