Aortic injury should be suspected when there are severe deceleration forces; classic physical examination findings may not be present Chest radiography is sensitive for the presence of aortic injury and should be followed by CT angiography when concerning Aggressive resuscitation and immediate surgical intervention are necessary for patients with aortic or great vessel injuries and signs of circulatory compromise such as tachycardia, poor perfusion, or hypotension Current Evidence Life-threatening injuries to the great vessels of the thorax carry a high mortality rate but are fortunately rare The aorta is the vessel most commonly involved in both blunt and penetrating trauma Rupture of the aorta occurs in approximately 10% to 30% of adults sustaining severe blunt trauma but is much less common in the pediatric population, affecting less than 1% of all children with blunt thoracic trauma Early detection of such injuries is vital for survival, as overall mortality rate of aortic rupture in children is 75% to 95%, with most deaths occurring at the scene Clinical Considerations Clinical Recognition Aortic injuries are most frequently associated with high-energy deceleration forces, commonly from automobile collisions, causing a shearing stress The descending aorta is fixed and the arch is mobile With deceleration, shearing takes place at the level of the ligamentum arteriosum, the most superior fixation point and the most common site of aortic tears in adults and children When a great vessel ruptures, massive blood loss may ensue The body’s compensatory mechanisms for the blood loss include an increase in both heart rate and total peripheral vascular resistance Relying solely on a decrease in systemic blood pressure to detect hemorrhage in children may be deceiving because children may lose 25% or more of their total blood volume before their systemic blood pressure is affected Children with significant bleeding may have a normal systolic blood pressure but be tachycardic and poorly perfused with a prolonged capillary refill time These findings should trigger aggressive resuscitation and urgent investigation of the source of hemorrhage prior to the onset of hypotension