What’s Your Diagnosis? Thoracic Aortic Syndromes in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Emergency Department Management of Rib Fractures right.

Case Presentation: Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management 

EMS presents with a 35-year-old man with acute chest pain that started after using cocaine. In addition to chest pain, he reports acute right arm weakness and numbness. His heart rate is 120 beats/min and his blood pressure is 220/110 mm Hg. While considering the options for blood pressure control, you wonder: if the head CT is negative and the blood pressure is below 180/90 mm Hg, should he be thrombolysed for an acute stroke? 

Case Conclusion

Given that the patient had severe hypertension, chest pain, and right arm weakness, there was concern for a propagating dissection flap causing stroke and chest pain. You ordered a stat head CT, since a stroke alert was initially called from EMS. The head CT was negative, and you then performed a CT aortogram. In anticipation of the outcome, upon initial assessment, medications were ordered to control his heart rate and blood pressure. As you suspected, the CT confirmed a large type A dissection. You started him on nicardipine and esmolol for rapid, titratable control of his heart rate and blood pressure, and blood products and labs were prepared. His blood pressure improved, and he was taken directly to the OR for operative repair. 

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Last Updated on December 27, 2021

2 thoughts on “What’s Your Diagnosis? Thoracic Aortic Syndromes in the ED

  1. History of cocaine use, uncontrolled blood pressure,chest painand CVA , needs to rule out aortic dissection. Thrombolysis is contraindicated .

    1. You are on it! Exactly correct. Chest pain plus neuro deficit in this clinical setting is highly suspicious for acute aortic dissection. Be sure to check out this month’s issue for a full review of the topic and listen to the interview with one of the authors on the podcast. I share a couple of interesting cases you might enjoy hearing about.

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