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Approach to the Mediastinum in Trauma:

Approach to the Mediastinum in Trauma:. Density vs. Width Tammy Washut MS4. Traumatic Injuries to Worry About. Mediastinal hematoma Aorta/great vessel injury Spinal hematoma. Rapid deceleration injury Blunt chest trauma- MVA, falls. The sudden stop causes the blood filled descending

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Approach to the Mediastinum in Trauma:

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  1. Approach to the Mediastinum in Trauma: Density vs. Width Tammy Washut MS4

  2. Traumatic Injuries to Worry About • Mediastinal hematoma • Aorta/great vessel injury • Spinal hematoma

  3. Rapid deceleration injury Blunt chest trauma- MVA, falls The sudden stop causes the blood filled descending aorta to “snap”. The aortic arch is fixed in position by branches from the arch. Mechanism Sudden deceleration as sternum hits steering wheel. As the aortic tube “snaps”, the intima is torn just distal to left sub- clavian artery.

  4. External signs • “Seat belt sign” • Chest ecchymosis • Sternal/Rib fractures

  5. Chest X-ray • Classically taught to look for widened mediastinum • Wide mediastinum = 8 cm • What is the problem with this??? • Wide mediastinum has a broader differential than paratracheal density

  6. Causes of Wide Mediastinum • Magnification • Rotation • Mediastinal hematoma • Spinal hematoma • Lymphadenopathy • Long intravascular volume • Obese patients

  7. Magnification

  8. Magnification • Film placed directly behind the patient • Initially used to determine the 8 cm criteria for wide mediastinum

  9. Magnification • Film placed under the backboard • 17% enlargement

  10. Magnification • Film placed in trauma bed • 25% enlargement

  11. Rotation 4 cm 7 cm Rotated Right Rotated Left

  12. 7 cm 4 cm Intravascular Volume Pre-Dialysis Post-Dialysis

  13. Lymphadenopathy

  14. Right Paratracheal Density • Composed of azygous vein and SVC • Density normally less than aortic arch • Increased = hematoma • Why? • Not affected by technical factors • Simple

  15. Right Paratracheal Density Normal Increased Density

  16. Mediastinal Hematoma • Other Signs: • PT stripe • Apical cap • Aortic Arch • NG deviation • Tracheal deviation

  17. Mediastinal Hematoma • Other Signs: • PT stripe • Apical cap • Aortic Arch • NG deviation • Tracheal deviation

  18. Mediastinal Hematoma • Other Signs: • PT stripe • Apical cap • Aortic Arch • NG deviation • Tracheal deviation

  19. Mediastinal Hematoma • Other Signs: • PT stripe • Apical cap • Aortic Arch • NG deviation • Tracheal deviation

  20. Mediastinal Hematoma • Other Signs: • PT stripe • Apical cap • Aortic Arch • NG deviation • Tracheal deviation

  21. Hypothesis: OHSU DATA Right paratracheal density is discriminatory sign in trauma patients with widened mediastinum

  22. Methods • 122 Trauma patients (2001-2003) • Screening Trauma chest radiograph • Mediastinal width > 8.0 cm • CT Chest w/contrast within 24 hours • Four readers of different levels of training • R paratracheal region evaluated

  23. Methods • Patients categorized by ISS • AIS by body region • Chest: 1-6 • Low risk: 0-2 (80 patients) • High risk: >2 (42 patients)

  24. Results • 19 mediastinal hematomas (15.6%) • 13 high-risk • 6 low-risk • 5 aortic injuries (4.1%) • 4 deceased (3.3%)

  25. Results

  26. Results

  27. Results

  28. Results

  29. Results

  30. Results Sensitivity

  31. Limitations • Single institution • Presented to readers in artificial setting • Relatively few hematomas • AIS/ISS scoring not useful as triage tool

  32. Strengths • Trauma patients with widened mediastinum • Confirmed by CT w/in 24 hours • Blinded analysis • Clinical information available on all patients

  33. Conclusions • Screening chest radiograph valuable in low/moderate risk trauma patients • Right paratracheal density valuable • Avoid CT in low-risk patients • 7.3% normal mediastinum • High risk patients should have CT

  34. Recommendations • Low risk patients with or without a wide mediastinum but no paratracheal density do not need to have CT of the chest • High risk patients with mechanism of injury (i.e. seatbelt sign) should go to CT regardless • Paratracheal density, not width, should direct further management

  35. Examples

  36. Possible Hematoma? • Yes- aortic rupture • Paratracheal density on right and loss of aortic arch definition

  37. Possible Hematoma? • Yes, but in this case it is lymphadenopathy in a high risk trauma patient • This patient should get a chest CT

  38. Possible Hematoma? • No- mediastinum is wide, but no paratracheal density • Patient is rotated to right

  39. Examples

  40. Examples

  41. Examples

  42. References • Melton SM et al., J Trauma 2004; 56:243-250 • Mirvis SE et al., Radiology 1987; 13:487-493 • Baker SP et al., J Trauma 1974; 14:187-196 • Woodring JH et al., Radiology 1984; 151:15-21 • Parmley LF et al., Circulation 1953; 17:1086-1101 • Woodring JH et al., J Emerg Med 1990; 8:467-476 • Woodring D et al., Ann Thor Surg 1984; 37:171-178 • Blackmore CC et al., Emerg Radiology 2000; 7:142-148 • Patel NH et al., Radiology 1998; 209:335-348 • Milne EN et al., Radiology 1984; 153:25-31 • Demetriades D et al., Arch Surg 1998; 133:1084-1088 • O’Connor CE et al., Emerg Med J 2004; 21:414-419 • Special thanks to Dr. Marc Gosselin and Dr Peter Verhey for references, • images and study data and slides.

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