Item ~?Mark <?

[> ai ~ ~ , GJIIA)
0. ld : 45 27 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 44-year-old male is found unresponsive and hypotensive at the scene of a high-speed

motor vehicle accident. He is intubated and immediately rushed to the emergency
department. The passenger in his car is pronounced dead at the scene. Physical
examination in the ED shows large bruises over the entire chest wall and collapsed neck
veins bilaterally. Lung exam reveals decreased breath sounds on the left side. Chest
x-ray shows a large left hemothorax and a widened, rightward-deviating mediastinum.
The most likely diagnosis is:

0 A. Esophageal rupture
o B. Aortic injury
o C. Myocardial rupture
o D. Myocardial contusion
o E. Diaphragm rupture
0 F. Bronchial rupture

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 4527 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 44-year-old male is found unresponsive and hypotensive at the scene of a high-speed

motor vehicle accident. He is intubated and immediately rushed to the emergency
department. The passenger in his car is pronounced dead at the scene. Physical
examination in the ED shows large bruises over the entire chest wall and collapsed neck
veins bilaterally. Lung exam reveals decreased breath sounds on the left side. Chest
x-ray shows a large left hemothorax and a widened.. rightward-deviating mediastinum.
The most likely diagnosis is:

A. Esophageal rupture (2%)

B. Aortic injury (75%)
C. Myocardial rupture (8%)
D. Myocardial contusion (4%]
E. Diaphragm rupture (4%)
F. Bronchial rupture (7%)

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Explanation: User ld
Patients suffering rapid deceleration blunt chest trauma are at high risk for aortic injury.
Oftentimes in the setting of high energy aortic injury secondary to blunt chest trauma,
aortic transection, circulatory collapse, and death are immediate sequelae. A minority of
patients with aortic injury have an incomplete or contained rupture. There are no clinical
findings specific for aortic injury, but hypotension, external evidence of trauma and
altered mental status are common. Once stabilized with airway, breathing, and
circulation secured, patients should be assessed with an upright chest x-ray. Findings
suggestive of aortic injury include a widened mediastinum, large left-sided hemothorax,
deviation of the mediastinum to the right and disruption of the normal aortic contour. In
these cases, the diagnosis can be confirmed via CT scanning. Management of patients
with established aortic injury includes antihypertensive therapy where appropriate and
immediate operative repair.

(Choice A) Esophageal rupture following blunt trauma is rare. Manifestations of

esophageal rupture include pneumomediastinum and pleural effusion. The diagnosis is
confi rmed with water-soluble contrast esophagography. Circulatory collapse is not seen.
(Choice C) In most instances of myocardial rupture, death is the immediate result.
Occasionally, the rupture is contained by the pericardium resulting in cardiac tamponade,

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 4527 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

Explanation: User ld
Patients suffering rapid deceleration blunt chest trauma are at high risk for aortic injury.
Oftentimes in the setting of high energy aortic injury secondary to blunt chest trauma.
aortic transection, circulatory collapse, and death are immediate sequelae. A minority of
patients with aortic injury have an incomplete or contained rupture. There are no clinical
findings specific for aortic injury, but hypotension, external evidence of trauma and
altered mental status are common. Once stabilized with airway, breathing, and
circulation secured, patients should be assessed with an upright chest x-ray. Findings
suggestive of aortic injury include a widened mediastinum, large left-sided hemothorax,
deviation of the mediastinum to the right and disruption of the normal aortic contour. In
these cases, the diagnosis can be confirmed via CT scanning. Management of patients
with established aortic injury includes antihypertensive therapy where appropriate and
immediate operative repair.
(Choice A) Esophageal rupture following blunt trauma is rare. Manifestations of
esophageal rupture include pneumomediastinum and pleural effusion. The diagnosis is
confirmed with water-soluble contrast esophagography. Circulatory collapse is not seen.

(Choice C) In most instances of myocardial rupture, death is the immediate result.

Occasionally, the rupture is contained by the pericardium resulting in cardiac tamponade,
in which case muffled heart sounds, hypotension and distended neck veins will be noted
on physical examination.
(Choice 0) Myocardial contusion classically causes tachycardia. new bundle branch
blocks or arrhythmia. Sternal fracture is a commonly associated finding.

(Choice E) Patients suffering diaphragmatic rupture may experience abdominal pain,

pain referred to the shoulder, shortness of breath and vomiting. Radiographic studies will
classically demonstrate abdominal viscera above the diaphragm and loss of the
diaphragmatic contour.
(Choice F) Bronchial rupture is a rare complication of severe blunt thoracic trauma.
Patients will present with a pneumothorax that does not resolve with chest tube
placement, pneumomediastinum and subcutaneous emphysema.
Educational objective:
High-energy, blunt, rapid deceleration trauma to the chest commonly causes aortic
injury. In most cases of aortic rupture, death is the immediate result. In patients with a
contained rupture, the diagnosis must be made quickly. Widened mediastinum and
left-sided hemothorax are classic chest x-ray abnormalities pointing to this diagnosis.

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