TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR THE INITIAL EVALUATION OF THE WIDENED MEDIASTINUM IN TRAUMA PATIENTS

Traumatic disruption of the thoracic aorta is an injury that is rapidl y fatal if not recognized and treated early, Increasingly, transesopha geal echocardiography (TEE) is being used to evaluate the thoracic aor ta after trauma with reported sensitivity and specificity rates of up to 100%. To confirm these results, we instituted a protocol using TEE as the initial diagnostic study for excluding a ruptured thoracic aort a in patients with widened mediastinum, All TEE studies were done by e xperienced cardiologists; 96% were done in the trauma receiving area, TEE studies were classified as positive, negative, or indeterminant. I ndeterminant studies were those in which the diagnosis of aortic injur y could not be excluded based solely on TEE findings. Because we were interested in using TEE as a ''definitive'' diagnostic modality, indet erminant studies were regarded as positive for our analysis, This prot ocol was used in 114 trauma patients over a 3-year period, TEE identif ied five thoracic aortic disruptions-three confirmed by aortography an d two by thoracotomy. TEE was read as indeterminant in 17 patients and further investigation with aortography showed no aortic injury in the se patients, TEE was negative in 89 patients who had no further evalua tion and were subsequently discharged or who died from other injuries, TEE failed to reveal significant lesions in three patients who had ao rtograms that revealed disruptions requiring thoracotomy, The use of T EE for the definitive diagnosis of ruptured aorta in this series yield s a sensitivity of 63% and a specificity of 84%. We conclude that whil e TEE is helpful in evaluating blunt chest trauma, the number of false positives and false negatives demands a more cautious approach to its use as a sole diagnostic study for ruptured thoracic aorta.