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