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Wide Mediastinum
Date: Fri, 6 Jun 1997 21:22:11 -0400 (EDT)
From: Todd Kelly [ToddKelly@aol.com]

A 57 you white male presented to my clinic 11 days s/p a restrained major mechanism head-on MVA while delivering pizzas. He was travelling 20 mph and the other car he never saw coming. He reports that his car was demolished and that the top of his steering wheel was severely bent. He was taken to a local hospital (not a trauma center) where ED C-spine, CXR, bilateral knee and bilateral ankle xrays were taken. He was diagnosed with a left transverse 2-3 mm inferior patella fracture and a left non-displaced tibial plateau fracture as well as "a slight widening of the superior mediastinum." As he was stable he was discharged after a physical exam with a left leg knee immobilizer and crutches and told to follow-up in my clinic.

In my clinic my exam was consistent with the above mentioned findings. Upon review of the xrays, I noticed his mediastinum to measure 9.5 cm (I don't know the technique of the xray). The aortic knob was distinct, there was no tracheal deviation, and the lateral view was normal. I also noted that he was hypertensive (R=162/96, L=174/100). He had no prior h/o hypertension. All other vitals were normal and he no complaints other than left knee pain and persistent right ankle pain and swelling.

I repeated his right ankle films (negative), referred him to an orthopedist, and ordered a CT of the chest. Would you have ordered the CT scan and should this have been performed prior to his d/c from the ED?

I'll tell you what I found later.

Todd Kelly, M.D.

Date: Sat, 7 Jun 1997 10:46:21 +0300 (IDT)
From: Avi Roy Shapira [avir@bgumail.bgu.ac.il]

This patient has two indications for an aortogram: mechanism and widened mediastinum. A negative CT will tell you nothing (except confirm the widened mediastinum). So you need an aortogram ASAP.

Avi

Date: Sat, 7 Jun 1997 12:27:44 +0100
From: Chris Taylor

> A 57 you white male presented to my clinic > 11 days s/p a restrained major > mechanism head-on MVA while delivering pizzas. > He was travelling 20 mph and > the other car he never saw coming. He > reports that his car was demolished > and that the top of his steering wheel was severely bent.

= significant mechanism of injury

> Upon review of the xrays, I noticed his > mediastinum to measure 9.5 cm (I don't > know the technique of the xray). I'm not sure of the "normal" - I am assuming you are saying it was widened.

> I repeated his right ankle films (negative), > referred him to an orthopedist, > and ordered a CT of the chest. > Would you have ordered the CT scan

no, an aortogram

> and should this have been performed prior to his d/c from the ED?

yes

Date: Sat, 7 Jun 1997 14:17:42 GMT
From: "Jose Acosta"

Todd,
With this mechanism and Xray's findings this patient should have had and angio the day of the original accident.

Jose A. Acosta

Date: Sat, 7 Jun 1997 09:14:59 -0600
From: Dr.Lango [plango@acnet.net]

You probably found a aortic disruption . Because of the mechanism of trauma and field report you must have a high susspicion of this injury . CT scan is OK , but maybe a Aortography could have given you the diagnosis with mayor accuracy. But any way , trauma is the most variated patology. What did you find?

Dr. Porfirio Lango
Trauma surgeon
Hospital General de Mazatlan

Date: Sun, 8 Jun 1997 08:44:28 -0400 (EDT)
From: Ken Mattox [kmattox@aol.com]

Although my own knee jerk reaction on the case as presented was to get an aortogram, incomplete data is often a TRAP, so I will give some varying views.

This patient is 57 years old, drives a truck and probabilly has driven a truck in the past. It is possible that this "widening" is a preexisting condition, including a old chronic injury to the aorta. It could be an atherosclerotic or dissecting aneurysm of the aorta. It could also be a condition in the ascending aorta. It would be very nice if we move our technology to include IMAGING on such cases. We could then help the presentor with determining if this were a supine or an upright chest X-Ray.

Second major problem, is that this "stable" patient walked into a clinic 11 DAYS after the accident. Back to Basics: WHY DID HE COME TO THE CLINIC? WHAT WAS HIS CHIEF COMPLAINT? It is obvious he was not brought in by EMS for evaluation following an auto accident. Being 11 days out, it is also likely that he has another condition.

A very simple approach would be to obtain a SIMPLE AP AND LATERAL upright repeat chest X-Ray in the Clinic. THis X-Ray might be stone cold normal. ALthough rare, I have seen patients bring in some one elses X-Ray and bring in very OLD x-rays. Repeat it before spending a lot of money. If the repeat chest X-Ray is normal go to the next paragraph

Third, this is a CLINIC, not a trauma center. It is likely that the clinic physician can obtain a CT in 1-2 hours whereas it will take 2-3 days for him to get an aortogram, and that would require a hospitalization. In the case as presented, in the environment he presented to, it is likely that the highest juice to squeeze ratio would be obtained by a CT scan. The CT would then guide additional evaluation and or therapy.

Date: Sun, 8 Jun 1997 18:52:29 -0400 (EDT)
From: Todd Kelly [ToddKelly@aol.com]

I would agree with your decision to obtain an aortogram if this patient presented to me in the Emergency dept. However, given that he is now 11 days s/p MVA this seemed a little too aggressive to me, thus I ordered the CT.

Not to bore you but it turns out that the CT scan was read as normal (prelim report). Should I still obtain an aortogram in this patient?

Todd Kelly, M.D.

Date: Sun, 8 Jun 1997 18:48:09 -060
From: Dr.Lango [plango@acnet.net]

At least do a trans esophageal ultrasound , if you don't feel like doing a aotrogram , but if I was your patient I'd thank you if you ruled out a mayor vessel silent injury .

Dr.Porfirio Lango Obregon

Date: Mon, 09 Jun 1997 13:00:22 +0200
From: Teddy Fagerström [teddy.f@swipnet.se]

So far so good, but a CT scan can not rule out an intima injury...

Teddy Fagerstrom MD
University Hospital of Linkoping Sweeden

Date: Mon, 9 Jun 1997 11:15:48 -0400
From: Jean Péloquin jean.peloquin@chg.ulaval.ca]

Too late!
CT in suspected aortic rupture could show blood in the mediastinum around the critical spot near the aorta in the acute situation. Even, with good timing and brisk injection of contrast media you can have a near aortogram image...
But now there still can be a problem that only the aortogram will detect. BTW the thoracic surgeon will demand aortography before considering surgery.

Date: 09 Jun 97 18:42:13 EDT
From: Stephen M. Stowe, M.D. [102747.3140@CompuServe.COM]

While a conventional CT might likely miss aortic damage a spiral CT has a high probability of picking up such damage. A CT is considerably less invasive than an aortagram and therefore it is reasonable to do it to see if other pathology may be present


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