Blunt injury to the thoracic aorta is one of those potentially devastating ones that you (and your patient) can’t afford to miss. Quite a bit has been written about the findings and mechanisms. But how do you put it all together and decide when to order a screening CT?

There are a number of high risk findings associated with blunt aortic injury. Recognize that they are associated with the injury, but are still not very common. They are:

• Fractures of the sternum or first rib
• Wide mediastinum
• Displacements of mediastinal structures (left mainstem down, trachea right, esophagus right)
• Loss of the aortopulmonary window
• Apical cap over the left lung

Here’s a sensible method for screening for blunt aortic injury, using CT scan:

• Reasonable mechanism (fall from greater than 20 feet, pedestrian struck, motorcycle crash, car crash at “highway speed”) PLUS any one of the high risk findings above.
• Extreme mechanism alone (e.g. car crash with closing velocity at greater than highway speed, torso crush)

Note on torso crush: I have seen three aortic injuries from torso crush in my career, one from a load of plywood falling onto the patient’s chest, one from dirt crushing someone when the trench they were digging collapsed, and one whose chest was run over by a car.