A 47-year-old unrestrained motor vehicle collision patient with hypotension and chest pain shows left base fluid on imaging and the nasogastric tube deviates to the right in the upper mediastinal region. What is the most likely diagnosis?

A 47-year-old unrestrained motor vehicle collision patient with hypotension and chest pain shows left base fluid on imaging and the nasogastric tube deviates to the right in the upper mediastinal region. What is the most likely diagnosis?

• A. Pneumothorax
• B. Aortic transection
• C. Myocardial contusion
• D. Esophageal rupture

Answer: (B)

Tearing of the thoracic aorta from blunt chest trauma is a life-threatening injury that presents with signs of major mediastinal disruption. The key imaging clues are mediastinal widening and left-sided blood in the pleural space (left hemothorax) from bleeding of the torn aorta. The nasogastric tube that deviates into the right side of the upper mediastinum reflects distortion of mediastinal anatomy from a mediastinal hematoma caused by an aortic injury, with the surrounding structures being pushed off their normal positions. Taken together with hypotension and chest pain after a high-velocity collision, these findings make traumatic aortic rupture the most likely diagnosis. This is an emergent situation requiring rapid stabilization and vascular consultation, with confirmation via CT angiography if feasible and definitive repair, often with endovascular approaches, in unstable patients.

Tearing of the thoracic aorta from blunt chest trauma is a life-threatening injury that presents with signs of major mediastinal disruption. The key imaging clues are mediastinal widening and left-sided blood in the pleural space (left hemothorax) from bleeding of the torn aorta. The nasogastric tube that deviates into the right side of the upper mediastinum reflects distortion of mediastinal anatomy from a mediastinal hematoma caused by an aortic injury, with the surrounding structures being pushed off their normal positions. Taken together with hypotension and chest pain after a high-velocity collision, these findings make traumatic aortic rupture the most likely diagnosis. This is an emergent situation requiring rapid stabilization and vascular consultation, with confirmation via CT angiography if feasible and definitive repair, often with endovascular approaches, in unstable patients.