Diagnosis: Thoracic Aorta Rupture (Torn Aorta)
The diagnosis is C. Thoracic aorta rupture (torn aorta), based on the classic triad of widened mediastinum, tracheal deviation to the right, and hypotension in a trauma patient. 1, 2
Key Diagnostic Features
The combination of findings in this patient is pathognomonic for traumatic aortic injury:
- Widened mediastinum is present in 92% of thoracic aortic rupture cases and represents mediastinal hematoma from aortic bleeding 2
- Tracheal deviation to the right is a specific sign of aortic dissection or rupture, caused by the mediastinal hematoma displacing the trachea 1, 2, 3
- Hypotension in the setting of widened mediastinum and hemothorax indicates impending free rupture and sudden death 4
The constellation of grossly widened mediastinum + hemothorax + transient hypotension is uniquely and strongly associated with patients who will progress to free aortic rupture (p < 0.00001), warranting immediate surgical intervention without traditional diagnostic studies 4
Why Other Options Are Incorrect
Massive hemothorax (Option A) would present with:
- Unilateral lung opacification, not expanded lungs
- Tracheal deviation away from the affected side, not toward the right
- No mediastinal widening 2
Pneumothorax (Option B) would show:
- Lung collapse, not expanded lungs
- Tracheal deviation away from the affected side in tension pneumothorax
- No mediastinal widening 2
Spontaneous pneumothorax (Option D) is excluded by:
- The trauma history
- Presence of widened mediastinum
- Tracheal deviation pattern inconsistent with pneumothorax 2
Critical Management Priorities
Immediate surgical consultation is mandatory upon identifying widened mediastinum in a trauma patient with hypotension, regardless of awaiting confirmatory imaging 1, 4
For hemodynamically unstable patients with this triad, the American College of Radiology recommends proceeding directly to surgery without traditional diagnostic studies, as the combination of grossly widened mediastinum + hemothorax + transient hypotension is a marker of impending sudden death from free rupture 4
If the patient can be stabilized temporarily, CT angiography with IV contrast provides sensitivity approaching 100% and specificity of 98-99% for confirming thoracic aortic rupture 1, 2
Common Pitfalls
Do not delay surgical consultation for additional imaging if the patient has transient hypotension responding to fluid resuscitation, as this represents impending free rupture 4, 5
Do not assume a normal mediastinum excludes aortic injury in severe blunt trauma, as 30% of ascending aortic ruptures present with normal mediastinal silhouette 6
The American College of Radiology warns against relying on chest X-ray alone to exclude aortic injury, as signs of hemomediastinum are more often false positive than true positive for aortic injury, but when combined with the specific pattern described here, they are highly specific 7, 1
Epidemiology Context
Approximately 20% of motor vehicle accident fatalities have autopsy findings of ruptured aorta, with only 9-14% reaching the hospital alive 7. In 45% of cases, the tear occurs at the aortic isthmus 7. With prompt recognition and definitive therapy, 60-80% of patients who reach the hospital alive can survive 7