Snapshot A 22-year-old man presents to the emergency department after a high-speed motor vehicle accident. He was in the passenger seat and was wearing a seatbelt. The patient reports chest pain with breathing difficulty. Vital signs are significant for a blood pressure of 135/95 mmHg and a pulse of 105/min. On physical exam, the patient is stable with a seatbelt imprint on the skin of his chest. An anteroposterior radiograph of the chest demonstrates an obscured aortic knob. Preparations are made to get a contrast-enhanced CT scan of the chest and trauma surgery is consulted. Introduction Definition blunt thoracic aortic injury Pathophysiology typically results from rapid deceleration, which is seen in high-speed motor vehicle accidents (majority of cases) falls from a significant height Anatomy aortic isthmus (most commonly affected) distal to the left subclavian artery this is the transition zone of a relatively more mobile ascending aorta and arch to the descending thoracic aortic, which is relatively fixed Presentation Symptoms chest pain intrascapular pain breathing difficulty or swallowing Physical exam steering wheel or seatbelt imprint on the skin surface left subclavian hematoma new interscapular murmur may find pseudocoarctation (upper extremity hypertension) absent bilateral femoral pulses Imaging Plain anteroposterior chest radiograph indication initial imaging of choice findings widened mediastinum abnormal aortic arch contour abnormal aortic knob tracheal deviation Tracheoesophageal echocardiography indication in hemodynamically unstable patients Contrast-enhanced chest CT indication in hemodynamically stable patients Treatment Operative aortic repair indication definitive treatment