Thoracic Aorta Rupture
The diagnosis is C. Thoracic aorta rupture (traumatic aortic injury). The combination of hypotension, tracheal deviation to the right, and widened mediastinum in a trauma patient is pathognomonic for acute traumatic aortic injury with impending or active rupture.
Key Diagnostic Features
The clinical presentation demonstrates the classic triad that strongly predicts traumatic aortic rupture:
- Widened mediastinum is the hallmark radiographic finding of aortic injury, present in 92% of cases 1, 2
- Tracheal deviation to the right is a specific sign of aortic dissection or rupture, caused by mediastinal hematoma displacing the trachea 1, 2
- Hypotension in trauma combined with these radiographic findings indicates either contained rupture with significant blood loss or impending free rupture 3
The 2022 ACC/AHA guidelines explicitly list both widened mediastinum and tracheal deviation to the right as signs of aortic dissection on chest X-ray 1. In the trauma setting, these findings carry even greater urgency.
Why Not the Other Options
Massive hemothorax (A) would present with:
- Unilateral lung opacification, not expanded lungs
- Tracheal deviation away from the affected side (pushed by fluid)
- No mediastinal widening 1
Pneumothorax (B or D) would show:
- Lung collapse, not expansion
- Tracheal deviation away from the affected side in tension pneumothorax
- No mediastinal widening 1
- The distinction between B and D is irrelevant here as neither fits the presentation
Critical Management Implications
This patient requires immediate surgical consultation and expedited definitive imaging 1. The combination of grossly widened mediastinum + hemothorax (implied by the clinical picture) + hypotension is uniquely associated with impending free rupture and sudden death 3.
- Patients with this triad have near 100% mortality if free rupture occurs 3
- Traditional diagnostic workup may be bypassed in favor of immediate surgical intervention in hemodynamically unstable patients 3
- If the patient is stable enough for imaging, CT angiography provides sensitivity approaching 100% and specificity of 98-99% 4, 5
Common Pitfalls
Do not delay for extensive imaging if the patient is unstable. The presence of transient hypotension that responds to resuscitation is deceptive—10 of 11 patients with this pattern in one series went on to free rupture and death 3. This represents a brief window for intervention before catastrophic exsanguination.
The "expanded lungs" mentioned in the question likely represents misinterpretation of the radiograph or refers to the overall appearance of a widened thoracic silhouette from mediastinal hematoma, not actual pulmonary hyperinflation 2, 6.