Pulmonology Book


Wide Mediastinum

Aka: Wide Mediastinum, Wide Mediastinum on Chest XRay, Mediastinal Widening
  1. See Also
    1. Penetrating Trauma (Gunshot Wound, Stab Wound)
    2. Blunt Chest Trauma
  2. Causes
    1. Emergent Conditions
      1. Aortic Dissection
      2. Aortic Rupture
      3. Pneumomediastinum (perforated lung, esophagus, trachea)
      4. Thoracic Aortic Aneurysm
      5. Thoracic Vertebral Fracture with Hematoma (high mechanism blunt Trauma)
    2. Non-emergent Conditions
      1. Lung Mass
      2. Mediastinal Mass (e.g. Lymphoma)
      3. Mediastinal Lymphadenopathy
      4. Pulmonary artery engorgement
      5. Hiatal Hernia
      6. Atelectasis
      7. Thyromegaly
      8. Thymoma
    3. Incidental findings
      1. Anatomic variants (azygous vein, duplicated SVC)
    4. Imaging technique
      1. Patient rotation
      2. Supine positioning
      3. Poor inspiration
      4. AP View Chest XRay (Magnifies mediastinum)
  3. Exam
    1. Blood Pressure in both arms
      1. Difference >10 mmHg between arms may suggest Aortic Rupture
      2. Difference may be evident on checking pulses in both arms
  4. Imaging: Chest XRay
    1. Widened Mediastinum Criteria
      1. Superior mediastinum >8 cm wide at the aortic knob (on PA View) OR
      2. Mediastinum >33% of the transthoracic dstance at the aortic knob (on supine AP View)
    2. Aortic Injury Findings
      1. Apical pleural cap (Pleural Effusion in the lung apex)
      2. Left mainstem Bronchus deviated downward
      3. Tracheal or esophageal deviation to the right
      4. High Rib Fracture (first or second rib)
  5. Imaging: Evaluation of Wide Mediastinum
    1. If initial xray was AP supine, repeat Chest XRay
      1. Obtain upright PA Chest XRay (maximize inspiration and avoid torso rotation)
    2. FAST Exam (serial exams)
      1. Pericardial Effusion (or Cardiac Tamponade)
      2. Pneumothorax (esp. Tension Pneumothorax)
      3. Hemothorax
    3. CT Angiogram Chest (typically with Abdomen and Pelvis to follow aorta)
      1. Preferred imaging evaluation of Wide Mediastinum
  6. Approach: Wide Mediastinum
    1. See Penetrating Trauma
    2. See Blunt Chest Trauma
    3. Obtain large bore Intravenous Access
      1. Obtain on the side opposite the injury
      2. Ready for Massive Transfusion (but do not overload with crystalloid)
    4. Imaging
      1. See Evaluation of Wide Mediastinum as above
    5. Emergent thoracic surgery or trauma Consultation indications
      1. Arterial bleeding (esp. aorta) identified on imaging
      2. Uncontrolled bleeding from pentrating Trauma
      3. Large or enlarging thoracic Hematoma (esp. airway compromise)
      4. Hemodynamic instability
    6. Hypertension Management in suspected aortic injury
      1. Target Blood Pressure 110 mmHg
      2. Esmolol drip (requires very close monitoring) or repeated Labetalol boluses
  7. Resources
    1. Radiology Master Class: Mediastinal Abnormalities
      1. https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page9
    2. Radiopaedia: Mediastinal Widening
      1. https://radiopaedia.org/articles/mediastinal-widening-differential
  8. References
    1. Swadron and Inaba in Herbert (2018) EM:Rap 18(30): 4-6, 8-9

Widened mediastinum (C0746459)

Concepts Finding (T033)
SnomedCT 363646005
Dutch mediastinum verwijd
French Médiastin élargi
German Mediastinumverbreiterung
Italian Mediastino allargato
Portuguese Mediastino alargado
Spanish Mediastino ancho, mediastino ensanchado (hallazgo), mediastino ensanchado
Japanese 縦隔拡大, ジュウカクカクダイ
Czech Mediastinum rozšířené
English mediastinal widening, mediastinum widening, widened mediastinum, Mediastinum widened, Mediastinal widening, Widened mediastinum (finding), Widened mediastinum
Hungarian Kiszélesedett mediastinum
Derived from the NIH UMLS (Unified Medical Language System)

You are currently viewing the original 'fpnotebook.com\legacy' version of this website. Internet Explorer 8.0 and older will automatically be redirected to this legacy version.

If you are using a modern web browser, you may instead navigate to the newer desktop version of fpnotebook. Another, mobile version is also available which should function on both newer and older web browsers.

Please Contact Me as you run across problems with any of these versions on the website.

Navigation Tree