Traumatic posterior mediastinal hematoma with left atrial compression: A case series of a rare, life-threatening entity

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BACKGROUND: Traumatic posterior mediastinal hematoma (TPMH) is a potentially life-threatening entity that, in rare instances, can lead to obstructive shock and sudden death secondary to left atrial compression (LAC). We describe the clinical course and outcomes of seven adult patients with TPMH and LAC. A brief literature review is presented. METHODS: Seven patients (ages spanning from the 20s to 80s) with TPMH and LAC were identified at a Level 1 trauma center from 2016 to 2023. The first 2 patients were identified following standard quality improvement case reviews for unexplained death. The subsequent five patients were prospectively identified during initial trauma evaluation. A retrospective evaluation of all patients was performed using the chart and computed tomography review. RESULTS: All seven patients sustained polytrauma. The mechanisms of injury were motor vehicle crash (4), motorcycle crash (1), golf cart crash (1), and bicycle crash (1). The first two patients with TPMH and LAC died shortly after admission (167 and 339 min) of suspected obstructive shock without evidence of significant hemorrhage. The subsequent five patients were identified during initial trauma evaluation, and each underwent aggressive fluid resuscitative management with 100% survival. CONCLUSIONS: TPMH may lead to significant LAC, which can result in sudden death. Our experience suggests that TPMH with LAC is associated with mid-thoracic spine fractures, rib fractures, and polytrauma secondary to high-energy mechanisms. Emphasis on its early recognition is paramount, with a focus on aggressive fluid and blood resuscitation, vasopressor support when needed, and immediate correction of any coagulopathy. In reviewing the literature, nonoperative management is often successful. Selective cases requiring angiography with embolization or hematoma evacuation via thoracotomy have been documented. Our goal is to raise awareness of this entity and its potential lethality. ( J Trauma Acute Care Surg . 2026;101: 173-177. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: V.

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