Image of the Day 1: Wide Mediastinum 1

This is a Chext X Ray finding belongs to a 72 years old male with known case of hypertension, hyperlipidaemia and Ischemic heart disease who presented with left sided chest pain radiating to the back and cough. The Chest X ray findings shows widened mediastinum  with blunting of left costophrenic angle. A Diagnosis of Leaking Dissecting Aortic Aneurysm was made.

At this point, the patient should undergo further radiological evaluation. At this point, contrasted enhanced CT scan should be performed. If patient to undergo operation, therefore, he should be referred to center with vascular surgery facility and have a CT Aortogram.

For doctors working in a district hospital. You should refer this case to a tertiary center. In a meantime, few simple measure should be taken which is 1) Aim systolic BP 90-100, 2) Adequate pain management, 3) Aim for a good urine output > 0.5 cc/kg/hr, 4) palpate for other pulses to ensure no co existing vascular problem, 5) Ensure two large bore IV branulla available, 6) At least 3 pints whole blood already being crossed matched.