A 61-year-old man in critical condition was admitted to the resuscitation room in the emergency department, presenting with chest pain and shortness of breath. His medical history included recent treatment with oral antibiotics for pneumonia, long-standing chronic obstructive pulmonary disease (COPD), a 40-pack-year smoking history, and a left popliteal artery embolus. He was also on chronic medications, including apixaban and aspirin. Initially, the patient did not recall or volunteer a recent history of repeated falls from standing height. An electrocardiogram (ECG) showed sinus tachycardia. A chest radiograph raised suspicion of an increased left-sided effusion, and a subsequent computed tomography pulmonary arteriography (CTPA) confirmed displaced fractures of the left sixth and seventh ribs. A large, expanding mediastinal hematoma measuring 15 cm in depth was also identified. An urgent CT aortogram was performed, revealing ongoing contrast extravasation without major vessel injury. The hematoma exerted a mass effect on the adjacent right ventricle, although no significant pericardial effusion or fluid was detected. The anticoagulant effect of apixaban was rapidly reversed following specialized hematological advice, using andexanet alpha. This intervention's potential risks and benefits were carefully considered, particularly regarding heparin unresponsiveness and the complications that might arise if bypass surgery became necessary. The patient then underwent an emergency sternotomy, during which a large anterior mediastinal hematoma was successfully evacuated without complications. He ultimately made a full recovery. Falls from less than 2 meters in height are becoming an increasing public health concern at a population level. In older patients, there should be a lower threshold for considering cross-sectional imaging. Many patients in this demographic are on direct oral anticoagulants, so it is crucial to consider and discuss the reversal of these agents with relevant multidisciplinary teams. This case highlights the complexities of polypharmacy and the medical challenges posed by the reversal agent andexanet alpha. Expanding mediastinal hematomas causing obstructive shock are rare, with most literature describing posterior rather than anterior mediastinal hematomas, particularly in cases resulting from a simple fall.
Keywords: andexanet alfa; chest wall injury; extra-pericardial tamponade; fall from less than 2 meters; major trauma in older adults; mediastinal hematoma; reversal of direct oral anti-coagulants; rib fractures; tamponade.
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