The widened mediastinum. Diagnostic and therapeutic priorities.
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.
Richardson
J D
JD
Department of Surgery, University of Louisville, KY 40202.
Wilson
M E
ME
Miller
F B
FB
D000328:Adult; D001013:Aorta, Thoracic / Q000293:injuries; D001019:Aortic Rupture / Q000000981:diagnostic imaging*; D001027:Aortography; D005260:Female; D006801:Humans; D008297:Male; D008482:Mediastinum / Q000000981:diagnostic imaging*; D009104:Multiple Trauma; D010533:Peritoneal Lavage; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*