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“Broken CT Scanner…” Case Conclusion December 7, 2013

Posted by Andy Jagoda, MD in : Cardiovascular , trackback

Case re-cap:

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…

Case conclusion:

Although you were tempted to discharge the 21-yearold patient with reproducible chest pain with costochondritis, you noticed that he appeared to have marfanoid features. Since your CT scanner was down, you decided to do a bedside ultrasound, which showed a large pericardial effusion with early signs of tamponade and an undulating flap within the descending abdominal aorta. You immediately started an esmolol and nicardipine drip and transferred the patient to the local tertiary care center where he was ultimately diagnosed with a type A dissection and underwent immediate repair. You reminded yourself to thank the nurse the next time you see him for not letting you dismiss the patient so quickly.

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Comments»

1. Joe - December 7, 2013

Acute aortic dissection and a negative d-dimer? Some studies suggest that a d-dimer is useful in the risk stratification of patients with suspected/possible acute aortic dissection. Would people please comment on this as I’ve used this test in patients I consider low risk and if negative have sent them home. thanks!!

2. Patrick Burnside - December 7, 2013

A negative D-Dimer in a rip roaring Type A dissection? No fibrin process in this patient? A very wise sage in EM one stated to me:

“The data remain consistent with the assertion that a d-dimer<500 ng/mL excludes aortic dissection in the first 24 hours."

PB
Charlotte, NC

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Last Modified: 09-18-2019
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