Medical Image of the Week: Wide Mediastinum Due to Lung Infiltrates

Figure 1. Panel A: Admission chest x-ray showing an apparent widened mediastinum. Panels B & C: CT scan showing consolidation in the posterior lungs bilaterally. Panel D: Chest x-ray showing resolution of his widened mediastinum with an increase in positive end-expiratory pressure.

The patient is a 65-year-old man patient with a past medical history of poorly controlled hypertension and coronary artery disease who was admitted after a witnessed code arrest. He was found down, and paramedics arrived within 5 minutes and started chest compressions. His initial CXR showed a wide mediastinum (Figure 1A) that was concerning for possible aortic dissection especially with his history of poorly controlled hypertension. Due to his hemodynamic instability a chest CT scan couldn’t be done initially, but the patient underwent a trans-esophageal echo that was negative for aortic dissection.

When the patient became more stable a chest CT scan with contrast was done and showed consolidation of the medial parts of both lungs with 7 bilateral rib fractures (Figure 1 B & C). The impression was either lung contusion from the aggressive chest compression as evidenced by the bilateral 7 rib fractures or aspiration in the dependent parts of the lung. His apparent widened mediastinum resolved with increasing the positive end-expiratory pressure (PEEP) on the ventilator within 48 hours (Figure 1D).

Huthayfa Ateeli MBBS, Laila Abu Zaid MD

Department of Medicine

University of Arizona

Tucson, AZ.

References

1. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma. 1997;42(5):973-9. [CrossRef] [PubMed]
2. Lai CC, Wang CY, Lin HI, Wang JY. Pulmonary contusion associated with chest compressions. Resuscitation. 2010;81(1):133. [CrossRef] [PubMed]

Reference as: Ateeli H, Zaid LA. Medical image of the week: widen mediastinum due to lung infiltrates. Southwest J Pulm Crit Care. 2015;10(2):77-8. doi: http://dx.doi.org/10.13175/swjpcc007-15 PDF