Diagnosis of traumatic mediastinal hematoma with transesophageal echocardiography

Role of Transesophageal Echocardiography in Blunt Chest Trauma

Patients who suffer blunt chest trauma are at risk for injury to the heart, and the thoracic aorta and its branch vessels. Unrecognized injury to the heart or aorta may lead to life threatening complications. Therefore, the physician caring for the trauma patient must be able to accurately and rapidly diagnose cardiac and thoracic aortic injury. Transesophageal echocardiography is an ideal tool to diagnose cardiac and aortic injury in the patient with blunt chest trauma because it provides high quality images of the heart and thoracic aorta and can safely and rapidly be performed in the emergency department, operating suite or intensive care unit. To utilize transesophageal echocardiography most effectively, the echocardiographer must be familiar with the indications, limitations, and piffalls of transesophageal echocardiography in patients with blunt chesttrauma. This review describes the role of transesophageal echocardiography in evaluating the patient with blunt chest trauma for cardiac, thoracic aortic, and mediastinal injury.

Posterior mediastinal hematoma after a simple fall in a patient with normal coagulation

Case

A 77-year-old woman presented with neck swelling and odynophagia following a fall from standing height. She had no history of antiplatelet or anticoagulant use. Computed tomography of the chest showed an isodense to hypodense soft tissue mass in the bilateral carotid space, retropharyngeal space, and posterior mediastinum. With no airway obstruction symptoms, the patient was placed on bed rest under close observation.

Outcome

The mass decreased in size spontaneously over the 10 days following symptom onset, accompanied by overall clinical improvement. The patient was diagnosed with a posterior mediastinal hematoma.

Conclusion

This is the first reported case of posterior mediastinal hematoma caused by a neck hyperextension injury secondary to a simple fall in a patient with normal coagulation. The outcome was good; however, emergency physicians should be aware that hematomas necessitating airway management may occur after a fall.

[Blunt traumatic aortic injury: importance of transesophageal echocardiography]

Traumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.

Transesophageal echocardiography for diagnosis of traumatic aortic injury: an appraisal of the evidence

BACKGROUND

An overview of the validity of transesophageal echocardiography (TEE) in patients suspected to have traumatic aortic injury (TAI).

METHODS

Computerized bibliographic search of trials from 1994 to 2002 evaluating the use of TEE to confirm the diagnosis of TAI. Seven relevant studies out of 204 were identified, involving 758 patients. The accuracy of TEE was analyzed by constructing summary receiver-operating characteristic (sROC) curves and computing areas under the sROC curve.

RESULTS

No prospective randomized trial was found. Although accuracy varied greatly, summary ROC curve found that TEE enjoyed a high diagnostic performance. Some study characteristics can affect accuracy.

CONCLUSIONS

Our findings seems to indicate that TEE is a valuable tool for diagnosing TAI, and its use as first-line evaluation of such patients can be supported; however, given the lack of randomized trials, no standard of care can be drawn from the present overview: future studies should look at this problem more carefully, and should be methodologically rigorous.

Management of Blunt Thoracic Aortic Injury

Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.

Transesophageal Two-Dimensional Echocardiographic Identification of Hiatal Hernia

We report a case of a middle-aged woman in whom a transesophageal echocardiogram showed a mass-like lesion posteriorly near the descending thoracic aorta. We were able to make a definitive diagnosis of this mass as a hiatal hernia because of a thick inner lining measuring 6-9 mm in thickness similar to the stomach mucosa, and the presence of a few microbubbles within the mass. In addition, the microbubbles increased considerably after 10 cc of agitated normal saline flush via a nasogastric tube.

Transesophageal Echocardiographic Diagnosis of a Liver Laceration Accompanied by Hemodynamic Instability

Transesophageal echocardiography (TEE) is a useful adjunct in the evaluation of trauma patients, particularly in the area of aortic injury and cardiac tamponade. Little has been written on the use of this modality in the evaluation of extra-cardiac injury. We present a case of a trauma patient in whom TEE was used to evaluate hemodynamic instability; during the course of the examination a previously undiagnosed liver laceration was identified. We report the diagnosis of a liver laceration in a trauma patient by novel use of the transesophageal echocardiographic imaging modality.

Practical points in evaluation and resuscitation of the injured child

The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.

Diagnosis of esophageal carcinoma because of findings on transesophageal echocardiography

A patient in whom transesophageal echocardiography was performed to evaluate a possible source of cerebral embolization. The fact that the probe could not be passed easily beyond 35 cm from the incisors suggested esophageal obstruction or compression. A mass was seen posterior to the left atrium that was heterogenous and contained blood vessels, suggesting a malignancy. There were no complications of the procedure. Esophageal adenocarcinoma was confirmed on biopsy. Transesophageal echocardiography may be diagnostic of paracardiac mediastinal masses, both benign and malignant. Great care must be taken if passage of the probe through the esophagus is met with resistance, to avoid serious complications.

Transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta: part II-atherosclerotic and traumatic diseases of the aorta

Transesophageal echocardiography (TEE) has provided an accurate new window for the evaluation of diseases of the thoracic aorta. Experience with TEE has led to an increased recognition of atherosclerosis of the thoracic aorta as a source of cerebral and systemic embolism. Certain features of aortic plaque morphology detected by TEE may prove to have prognostic and therapeutic significance. The intraoperative assessment of thoracic aortic atherosclerosis by TEE may guide modifications in surgical techniques and aortic manipulations that reduce the incidence of perioperative neurologic complications. TEE has also become a valuable tool for the diagnostic evaluation of patients with blunt chest trauma. The precise role of TEE in the management of these disorders is currently under investigation.

Use of Transesophageal Echocardiography for the Assessment of Traumatic Aortic Injuries

Acute traumatic lesions of the thoracic aorta or its branches (TLA) constitute highly lethal yet treatable injuries that are increasingly diagnosed in surviving patients. Traumatic disruptions are limited to the region of the aortic isthmus in approximately 90% of cases. Unlike aortography, usually referred as the gold standard diagnostic technique, transesophageal echocardiography (TEE) is a noninvasive imaging modality that can be rapidly performed at the patient bedside. Accordingly, TEE is being increasingly used as a first-line screening test for the evaluation of patients with suspected TLA. The TEE signs associated with TLA depend on the anatomic type of aortic disruption. After a period of validation, multiplane TEE allows accurate diagnosis of traumatic disruptions of the aortic isthmus, with a sensitivity of 88% (range, 57%-100%) and a specificity of 96% (range, 84%-100%). False-negative TEE results have been mainly attributed to lacerations of aortic branches. Accordingly, aortography must be routinely performed when a traumatic injury to brachiocephalic arteries is suspected. False-positive TEE findings have been associated with the presence of ultrasound artifacts or atherosclerotic changes that mimic TLA. Accurate determination of the depth of aortic wall tears and diagnosis of blunt cardiac injuries during the TEE study are crucial to guide patient management. The presence of TEE signs associated with imminent risk of adventitial rupture should lead to prompt surgery. The use of TEE as a first-line imaging modality simplifies the initial assessment of patients at high risk for TLA and helps guide acute management.

[Transesophageal echocardiography for diagnosis of traumatic injuries to the major intrathoracic vessels in 150 patients: the effect of the learning curve]

OBJECTIVES

To evaluate the role of transoesophageal echocardiography (TOE) in the management of patients with suspected traumatic lesions of the thoracic aorta (TLA) and its branches; to assess the influence of the learning curve on the diagnostic accuracy of TOE for the identification of TLA.

STUDY DESIGN

Retrospective study.

PATIENTS

The study included 150 patients (age: 41 +/- 17; Injury Severity Scale score: 31 +/- 17) who were admitted during a 4-year period for severe blunt chest trauma and who underwent a TOE study.

METHODS

TOE were performed with either a monoplane (n = 54) or a multiplane probe (n = 96). In all cases, TLA were confirmed by angiography, computed tomography, surgery, or necropsy. Initially performed routinely, angiography was subsequently indicated when the TOE study was inconclusive or when a disruption of supraaortic arteries was suspected. Echocardiographic studies were reviewed by an experienced reader who was unaware of the medical history and initial conclusions. To evaluate the influence of the learning curve on the diagnostic accuracy of TOE, these conclusions were compared with the initial interpretations.

RESULTS

A TLA was recognized in 25 patients out of 150 (17%), and evidenced using TOE in 22 of them. Three false negative and two false positive TOE results (needless thoracotomy) were recorded. After a learning period, the rate of inconclusive TOE studies decreased (18/150 vs 7/150: P < 0.05) and no false positive finding was recorded. The sensitivity and specificity of TOE for the diagnosis of TLA were 88 and 100%, and positive and negative predictive values were 100 and 97%, respectively.

CONCLUSIONS

TOE is an accurate imaging technique for the diagnosis of TLA located at the aortic isthmus. However aortography becomes essential when injuries of the aorta branches are suspected. A learning period is required to improve the specificity of TOE for this indication.

[Post-traumatic hematoma of the esophagus]

A 20-year-old man was admitted after a traffic accident for a closed chest trauma. Initial evaluation showed a sternal fracture with a minor pneumomediastinum. Twenty-four hours later be experienced an acute respiratory failure, due to total left pulmonary atelectasis from indirect compression of the left main stem bronchus. Mediastinal widening at the postero-superior level was visualized by CT scan. The aortogram was normal. Thoracotomy showed a moderate left haemothorax, associated with an intramural haematoma of the low thoracic oesophagus which was respected. The time course was uneventful, except repetitive atelectases treated by fibrescopic aspiration. Oesophageal haematoma secondary to chest trauma is a rare injury, with around 10 cases reported in the literature. Compression of tracheobronchial axis is exceptional. Because of the delayed occurrence of such a complication after chest trauma, with sternal fracture, close clinical surveillance and CT scans are essential.

Quantification of traumatic hemomediastinum using transesophageal echocardiography: impact on patient management

STUDY OBJECTIVES

To determine whether the quantitative evaluation of hemomediastinum using transesophageal echocardiography (TEE) is predictive of the presence of a traumatic disruption of the thoracic aorta (TDA) or its branches in patients who have sustained severe blunt chest trauma.

DESIGN

Retrospective study.

SETTING

ICU of a tertiary referral teaching hospital.

PATIENTS

Forty-one patients sustaining severe blunt chest trauma (32 men, nine women; mean age, 43+/-16 years; mean Injury Severity Score, 39+/-22) who underwent a TEE study were divided into two groups, patients with (group TDA+, n=15) or without (group TDA-, n=26) major vascular injury diagnosed using an alternative method such as aortography, surgery, or necropsy. The control group included 41 age- and sex-matched patients with an unremarkable TEE study performed to rule out an intracardiac source of emboli.

INTERVENTIONS

The presence of hemomediastinum was quantitatively assessed by measuring the distances between the esophageal scope and anteromedial aortic wall (distance 1), and between the posterolateral aortic wall and left visceral pleura (distance 2) at the level of the aortic isthmus. An observer who was unaware of both medical history and final diagnosis measured the distances.

MEASUREMENTS AND RESULTS

In group TDA+, TEE demonstrated aortic injuries in 13 patients, revealed an isolated hemomediastinum in one patient (ruptured intercostal arteries), and was unremarkable in the remaining patient, who sustained a disrupted right subclavian artery. No associated major vessel injuries were diagnosed in the group TDA- (normal aortograms). When compared to the control group, mean distances were greater in patients with chest trauma (distance 1=5.5+/-4.4 mm vs 2.7+/-0.8 mm, p=0.001; distance 2=3.8+/-5.0 mm vs 1.2+/-0.3 mm, p=0.02). The corresponding distances were even greater in group TDA+ when compared with group TDA- (distance 1=8.6+/-5.9 mm vs 3.7+/-1.5 mm, and distance 2=7.1+/-7.0 mm vs 2.0+/-1.7; for both differences, p<0.01). A threshold value of 5.5 mm for distance 1 or 6.6 mm for distance 2 had a sensitivity of 80%, a specificity of 92%, a positive and negative predictive value of 86% and 89%, respectively, for the diagnosis of underlying major vascular injury.

CONCLUSIONS

TEE allows quantitative assessment of traumatic hemomediastinum. The presence of a large hemomediastinum requires further evaluation by aortography, even if the thoracic aorta appears normal during the TEE examination, in order to rule out an underlying major vascular injury which may be outside the field of view of the echocardiographer.

Transesophageal ultrasonography of the normal canine mediastinum

The mediastinum of eight normal research dogs was examined by transesophageal ultrasonography with a 5 MHz frequency transducer to establish a baseline for future use of this new imaging modality as a diagnostic tool. Each examination consisted of 360 degree scans in both transverse and sagittal planes from the thoracic inlet to the esophageal hiatus. Dissections of four of these research dogs were then performed to confirm transesophageal ultrasonography findings. Transesophageal ultrasonography of the mediastinum was a good imaging modality for the evaluation of the heartbase, the major cranial mediastinal vessels, the descending aorta, and occasionally part of the azygos vein. Anatomic orientation was best obtained by beginning the examination at the heart base. Lymph nodes and smaller caliber vessels could not be distinguished from surrounding tissues; however, Doppler ultrasound was useful for identifying the smaller vessels. Although a 5 MHz frequency transducer is preferred for transesophageal echocardiography, a higher frequency transducer would improve the resolution of the images of small near-field structures and may be more appropriate for mediastinal imaging.

Use of transesophageal echocardiography for diagnosis of traumatic aortic injury

This prospective study was conducted to describe the signs on transesophageal echocardiography (TEE) associated with traumatic aortic injury (TAI). Twenty-eight patients with TAI underwent TEE, and they were compared with a control group of 30 thoracic trauma patients without aortic injury. The TEE signs were classified as direct or indirect signs, and the quality of imaging was assessed. Patients' TEE images were compared with their anatomic lesions. The direct signs were thick stripes (n=19), false aneurysm (n=7), aortic dissection (n=6), free-edge intimal flap (n=15), aortic wall hematoma (n=2), fusiform aneurysm (n=13), and complete aortic obstruction (n=2). The indirect signs included minor increases in aortic diameter (n=7), impairment of the aortic Doppler color flow (n= 18), and an increase of aorta-probe distance, indicating hemomediastinum (n=23). TEE allowed diagnosis of recently described limited intimal lesions frequently missed by other conventional methods, and permitted rapid diagnosis of complete rupture in which fast degeneration means that more time-consuming methods are not practicable. Significant blurring of the aortic outline was noted in 20% of cases and intraluminal artifacts were observed in 36% of cases, but neither sign impaired accurate diagnosis of TAI. The echocardiographic signs of aortic injury are complex and may be confined to a short section of the aorta. Therefore, examination by a physician highly trained in echocardiography is necessary in such cases.

Angiography in blunt thoracic aortic injury

PURPOSE

Recent studies have suggested that transesophageal echocardiography (TEE) can be used as the primary imaging method in patients suspected of traumatic rupture of the thoracic aorta. A segment of the aorta and the aortic arch branches cannot be adequately evaluated in all patients by TEE. To assess the impact of these limitations of TEE, this retrospective study examined the aortographic features of traumatic aortic or great vessel injuries in a large number of patients.

MATERIALS AND METHODS

We retrospectively reviewed clinical and imaging features of 89 patients with a history of blunt chest trauma and angiographic evidence of traumatic injury to the thoracic aorta or to its branches.

RESULTS

Of these 89 patients, 72 had aortic rupture alone. One (1%) of these ruptures occurred at the distal ascending aorta, a potential blind spot for TEE. Seventeen patients (19%) had 24 injuries to the aortic arch branches: in 14 of these 17 patients, the aorta was intact, whereas three patients also had aortic rupture. Seventy percent of the injuries to the aortic arch branches were not suspected on physical examination.

CONCLUSION

Twenty percent of patients in our retrospective series had traumatic involvement of aortic arch branches or the distal ascending aorta. These vascular injuries may be suboptimally assessed or overlooked if TEE is used as the sole imaging modality in the evaluation of patients with blunt chest trauma.

Diagnosis of esophageal varices by transesophageal echocardiography: a mimicker of aortic disease

The use of transesophageal echocardiography is well established in the emergency department diagnosis of traumatic aortic diseases. It has very high sensitivity and specificity compared with those of other tests. The physician performing transesophageal echocardiography should be aware of conditions that can mimic aortic pathologic conditions, thus leading to an incorrect diagnosis. We report a case in which the presence of previously undiagnosed esophageal varices mimicked traumatic aortic disease.

Chest trauma: the role of transesophageal echocardiography

Aortic and cardiac injury is commonly seen with severe chest trauma and contributes to the morbidity and mortality of automobile accidents. Transesophageal echocardiography is emerging as an important diagnostic tool for the evaluation of cardiovascular injury in the setting of acute chest trauma, and anesthesiologists should be familiar with the echocardiographic features of these traumatic lesions.

Transesophageal echocardiography

This article presents an overview of the benefits and efficacy of transesophageal echocardiography (TEE) in the critically ill patient. The echocardiographic evaluation of ventricular function both regional and global, is discussed with special emphasis on ischemic heart disease; assessment of preload, interrogation of valvular heart disease (prosthetic and native) and its complications; endocarditis and its complications; intracardiac and extracardiac masses, including pulmonary embolism; aortic diseases (e.g., aneurysan, dissection, and traumatic tears); evaluation of patent foramen ovale and its association with central and peripheral embolic events; advancements in computer technology; and finally, the effect of TEE on critical care.

Computed tomography vs clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma--a cost analysis approach

OBJECTIVE

To compare contrast computed tomography (CT) for evaluating abdominal and vascular chest injuries after emergency room resuscitation with multidisciplinary management based on bedside procedure (BP), e.g., peritoneal lavage, abdomen ultrasonography urography and, if indicated, CT and/or aortography or transesophageal echocardiography.

DESIGN

Randomized study.

SETTING

Emergency, critical care and radiology departments in a trauma center.

PATIENTS

The study was performed in 103 severe blunt trauma patients with a revised trauma index < 8, admitted over a 16 month period and divided into group (G1, n = 52, CT management) and group 2 (G2, n = 51, BP management).

INTERVENTIONS

A relative direct cost scale used in our trauma center was applied, and cost units (U) were assigned to each diagnostic test for cost-minimization analysis (abdomen ultrasonograph = 7.5 U, peritoneal lavage = 8 U, urography = 9 U, computed tomography = 9 U, transesophageal echocardiography = 13.5 U, and aortography = 15 U). One unit is approximately equivalent to $43.7.

RESULTS

Injury severity score (ISS) was 31.7 +/- 15.4 in G1 and 33.8 +/- 18.3 in G2. Sensitivity for CT was 90.4% (G1) vs 72.5% for BP (G2) in abdomen (P < 0.01) and 60% in chest for evaluating mediastinal hematoma etiology (G1). As Table 2 shows, G1 needed 59 tests for evaluating injuries (1.1 +/- 0.3 tests patient) while G2 required 81 tests (1.68 +/- 0.8 tests/patient) (P < 0.01). The total relative cost was 538 U for G1, 7.04 +/- 2.2 U cost/injury and 10.3 +/- 3.3 U/evaluation of trauma vs 698 U for G2, 9.84 +/- 5.03 U cost/injury and 13.68 +/- 8.5 U/evaluation (P < 0.05).

CONCLUSIONS

This cost-minimization study suggests that CT is a more cost-effective method for the post-emergency room resuscitation evaluation of severe abdominal blunt trauma than the multidisciplinary BP. Chest CT is a screening method for mediastinal hematoma but not for etiology.

Routine transesophageal echocardiography for the diagnosis of aortic disruption in trauma patients without enlarged mediastinum

OBJECTIVE

To assess the value of routine transesophageal echocardiography (TEE) in diagnosing traumatic disruption of the aorta (TDA) in trauma patients presenting without enlarged mediastinum on chest x-ray films.

DESIGN

Prospective study.

MATERIALS AND METHODS

TEE was routinely performed to exclude the presence of TDA in patients who sustained severe trauma secondary to abrupt deceleration collisions and presented with an upper mediastinum of fewer than 8 cm on supine chest x-ray films. Patients were divided into two groups according to the presence (group I) or absence (group II) of mediastinal hematoma diagnosed during TEE examination. Radiographic signs regarded as indicators of the presence of TDA were evaluated in both groups.

RESULTS

Among the 40 consecutive patients studied, TEE demonstrated two cases of TDA associated with a mediastinal hematoma that were confirmed by both aortography and surgery. One of the patients had a normal mediastinum on presentation chest x-ray films, and the other only exhibited a blurred aortic knob. Radiographic mediastinal abnormalities suggestive of TDA were observed in 13 patients, but chest x-ray films were unremarkable in 12 patients. Twenty patients had multiple rib fractures. The frequency of chest radiographic abnormalities was not significantly higher in group I (n = 6) when compared with group II patients (n = 34). TEE examination demonstrated a normal thoracic aorta in 35 patients and was nondiagnostic in 3 patients (normal aortography).

CONCLUSION

TEE should be routinely performed in victims of violent deceleration collisions, even in patients presenting apparently normal mediastinum on supine chest radiography.

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption

BACKGROUND

Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality.

METHODS AND RESULTS

Thirty-two consecutive trauma patients (mean age, 40 +/- 16 years) with suspected TDA (violent deceleration accident and mediastinum > 8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n = 10) and (2) traumatic intimal tears (n = 3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57 +/- 15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA.

CONCLUSIONS

TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.