A 35-year-old man involved in a high-speed head-on collision presents with severe interscapular pain. He is haemodynamically stable. Chest X-ray shows a widened mediastinum with blurring of the aortic knuckle and deviation of the trachea to the right. Blood pressure in the right arm is 160/90 mmHg and in the left arm 120/70 mmHg. What is the definitive next investigation?
- A Transoesophageal echocardiography
- B CT angiography of the chest ✓
- C Aortography via femoral arterial catheterisation
- D Serial chest radiographs over 6 hours
Correct answer: B. CT angiography of the chest
Explanation
Deceleration injury causing traumatic aortic rupture typically occurs at the isthmus just distal to the left subclavian artery. Widened mediastinum on chest X-ray plus differential arm pressures demands urgent imaging, and contrast enhanced CT angiography is now the standard first line diagnostic test, having replaced invasive aortography. Transoesophageal echo is used when CT is unavailable or the patient is too unstable for transport. Serial radiographs delay diagnosis dangerously in a lesion that can rupture freely at any time.
Reference: Sabiston Textbook of Surgery, 21st ed.
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