The next week, you are working at a free-standing ED where the patients are checking in at record volume. You are getting pressure to see and discharge patients as fast as possible when you see a 21-year-old male presenting with chest pain radiating to his back, along with some shortness of breath. The patient reports no improvement in symptoms with over-the-counter analgesics. The patient plays on the local varsity basketball team. He has no known medical history, and his social history is negative for tobacco, alcohol, or illicit drugs. He appears slightly anxious and has a blood pressure of 155/90 mm Hg and a heart rate of 95 beats/min. He is tall and thin and has reproducible chest tenderness. Your CT scanner has unexpectedly gone down and is unavailable for the rest of the night. ECG shows a normal sinus rhythm without evidence of ischemia and a plain chest radiograph appears normal. As you start to watch your department getting backed up, the nurse states that he is concerned about this patient. You assess the patient as low risk for pulmonary embolism, so you decide to get a D-dimer, which comes back negative. You wonder if this patient has something more significant and what your diagnostic options are…
Knowing the CT scanner is down, what steps could you take?
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Last Updated on January 26, 2023
Transthoracic echo to rule out RV strain and looking for sign of aortic dissection
go for enzyme assay to rule out ac pancreatitis. if normal treat as connective tissue disorder.
What are the lung sounds ?
Heart sounds
Pneumothorax ?
Inspiratory/ exploratory films looking for pneumothorax.
Transfer to a hospital with working ct and perform ct angio to eval for dissection.
MRI with contrast : aortic dissection
acute aortic syndromes
Ultrasound! Both to evaluate for pneumothorax, and to take a look at the heart for secondary evidence of a PE. (Given the BB history I’ll put my bets on the ptx, though!)
this smells like dissection in a Marfan person
what to do diagnostically
– feel for differences between radial pulses and between radials and posterior tibials
– likewise measure BP in both arms and compare with BP in legs
Aortic dissection? Check pulses / BP bilaterally….
The obvious clues point to aortic dissection in this mafanoid young man with an otherwise negative work up. Suspicion ought to be high enough to warrant performing a careful focuses exam (listening for an aortic insufficiecy murmur, checking bilateral BPs and pulses), considering an ECHO if CT is down, and starting therapy concurrently with O2, IV, monitor, analgesics and BP/HR control. As we know d-dimer and CXR is not sensitive enough to r/o dissection. Transfer to a facility with CT surgery capabilities ought to be considered early as well.
Chest pain radiating to the back in a young patient tall and thin with normal ECG prompts to rule out acute aortic syndrome (also if D dimer is negative) and so I would order urgent transthoracic echocardiogram (and if negative or doubtful a transesophageal echocardiogram)
Aortic dissection
dissection
I would still be worried about dissection. There is not a lot of good literature out there that says a neg d dimer rules out a contained dissection. I guess the next best study would be a transesophageal echocardiogram. Good luck getting that emergently!
Obviously, a stat chest x-ray is in order. His risks with his body habitus are spontaneous pneumothorax and he certainly has the body type to worry about possible Marfan’s with aortic dissection. Plain film would obviously identify the ptx and widened mediastinum would suggest possibility of aortic dissection.
Do a chest Xray
Pneumothorax due to ruptured pulmonary bullae.
Insert needle to see if air comes out.
Given the symptoms and his physical description, an Aortic Dissection in a patient with possible connective tissue disorder is a very real concern.
This patient most likely has aortic dissection.
If formal echocardiography is available start with TTE, if negative and available, TOE. If lucky enough to have MRI consider MRI/MRA in discussion with cardiologist/radiologist. If stable and no murmur (i.e no signs of type A dissection) control BP with good analgesia (titrated IV morphine followed by alpha and beta blockade e.g labetalol 10mg IV titrated to effect (BP<120/80)
Key issue is to exclude aortic dissection and patient cannot go home until this is done.If echo/MRI unavailable Investigate when CT scan will be available, and either wait or consider transfer to centre with CT.
blood pressure both arms and consider echo is available
Does his thumb extend outside the palm when he flexes it across then and are his joints hyper elastic.
Marfan’s
Cardiac Ultrasound – and Ultrasound of Aorta –
and check bp/pulse in both upper extremities and differential between arm and ankle BP/Pulse
r/o dissection of aortic aneurysm –
r/o hypertrophic cardiomyopathy
r/o pericarditis
I would also ask about family history of aortic pathology, and thromboembolism.
I would like to know what was the patient doing when the pain started. At what time did it start, and at what time did it peak. Did the pain migrate, starting anterior chest then moving to the back.
I would check for pulse deficits and blood pressure in both arms. Check femoral pulses and consider taking both legs blood pressure.
D Dimer rules out dissection pretty well (what is the number, was it a qualitative test or a quantitative test?). Then it does not rule out intramural hematoma or penetrating aortic ulcer which are part of aortic syndromes.
If he is tall and thin, and looks like a Marfan syndrome, other imaging is definitively indicated.
The options are TEE or MRI. If further history is concerning, I would immediately treat the patient medically. If no imaging is available, or is delayed, the patient should be transfered to a facility with imaging and cardiothoracic surgeons available.
For an athlete. ..he appears to be tachycardic and for his age he appeared to be hypertensive. Apart from all investigation done I will do cardiac marker and send him to nearest emergency department with full hospital set up for ct scan. May consider beta blocker for meanwhile.
Transthoracic cardiac ECHO to evaluate the heart and proximal aorta can show many potential abnormalities; also PTX can be Dx with U/S. AMI dx with cardiac enzymes. DDX; AMI, PTX, pericarditis, acute valvular failure, aortic dissection. I would highly consider transfer for CT- an easy step!
Question nurse re cause for concern.. change in vital signs? Increased pain?
Re-assess to stratify risk of dissection +/- tamponade or pneumothorax further – Vital signs, Perfusion, JVP (tamponade), lower limb pulses and BP both left and right brachial –
Bedside ultrasound for pneumothorax, percardial effusion and Intimal flap in abdominal aorta .If significant risk consider formal echocardiogram (ED v cardiology) v local aortogram (cath lab and radiology options ) v transfer to another centre with appropriate diagnostic and management services for CTA if stable. If no specific concerns and pain inadequately controlled then observation unit admission for pain management and repeat Cardiac markers would mitigate residual risk.
Aortic Dissection
check BP in both arms; upright PA CXR
since he is a basketball player , and he is initially with chest pain with back radiation , i will go for Boerhaves syndrome.
reproducible chest tenderness can also poke me to rib fracture not visible on chest x ray or say MUSCULOSKELETAL injury of thoracic cage.
I am worried that this patient has a thoracic aortic dissection as a complication of his underlying Marfans syndrome.
I would make arrangements for him to have a CT scan immediately at the hospital or transfer him to the hospital for inpatient evaluation. If CT is negative, proceed to MRI. (Admission with a consult to Cardiology for a TEE is another option.).
Diagnostic options are :Marfan’s syndrome with aortic dissection.
he would need an urgent Echo cardiogram.
Tall and thin is the clue for spontaneous pneumothorax and pneumomediastinum. My diagnostic options are lateral chest and servical radiography for pneumomediastinum and ultrasonography for confirmation of pneumothorax
Check bilateral upper extremity BP’s
Dx: Aortic Dissection
Would start IV beta blockade followed by IV nicardipine or nipride and transfer to the closest hospital with CT surgery capabilities.
Spontaneous Pneumothorax
Since the Ct scan is down, my concern is marfans syndrome and aortic aneurysm dissection. One should check the pulses and see if they are equal and check for radial femoral delay. Also do we at least have echocardiogram services? A TEE would be another option. I assume the chest X-ray has been done, and since the D-dimer was negative PE is probably negative and pneumonia unlikely. Thanks for all you do! LSP
since he is a low risk for PE and D-dimer negative will review the history for PE rule out criteria PERC ,if all questions are answered No then PE ruled out.My next step to get an expiratory cxr for pneumothorax since he has some marphenoid features.if this normal then the next step is to rule out aortic dissection,check BP on both sides and accurately measure the mediastinum
fortunately, the negative D-Dimer has also ruled out an acute dissection. The test might still be negative with an intramural hematoma, but that would be quite a rare event. The chance of your pt. having a significant aortic problem must be much less than 1%. He is safe to be discharged.
Chest pain radiating to the back usually represent a serious condition that requires prompt management.
The best course is to transfer the patient to a facility with adequate functioning equipment.
He could have a perforated ulcer, dissecting aneurysm, cancer or other conditions. Exams that could be done in the ED are US, GED and tilt rest. If all of those are negative, time was wasted by not referring the patient to a facility with functioning equipment.