Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management -
$59.00
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Publication Date: December 2021 (Volume 23, Number 12)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 12/01/2024.
Author
Anthony Hackett, DO, FACEP, FAAEM, FRSM
Attending Physician, CHI St. Joseph Regional Hospital; Clinical Assistant Professor of Emergency Medicine and Clinical Clerkship Director, Texas A&M University School of Medicine, Bryan-College Station, TX
Jonathan Stuart, DO, MS
Assistant Professor of Emergency Medicine, Uniformed Services University, Bethesda, MD; Critical Care Fellow, University of Washington, Seattle, WA
Douglas L. Robinson, DO, MS
Medical Director, 3rd Battalion, 75th Ranger Regiment, Fort Benning, GA; Assistant Professor of Emergency Medicine, Mercer University School of Medicine, Columbus, GA
Peer Reviewers
Daniel Eraso, MD
Assistant Professor, Department of Emergency Medicine, University of Florida College of Medicine–Jacksonville, Jacksonville, FL
Trevor Pour, MD
Assistant Professor of Emergency Medicine, Associate Program Director, Emergency Medicine Residency, Icahn School of Medicine at Mount Sinai, New York, NY
Abstract
Acute aortic syndromes include aortic dissection, penetrating atherosclerotic ulcer, and intramural hematomas, but aortic dissection is the most common and the deadliest. This review summarizes the latest evidence on developing a differential for aortic dissection when common complaints, such as chest pain, abdominal pain, and syncope are also present. Recent evidence on the optimal uses of emergency department imaging studies and risk stratification tools are reviewed, along with special considerations in the management of penetrating atherosclerotic ulcer and intramural hematoma. Pharmacologic therapies for managing hemodynamic parameters and shock, and indications for operative intervention are also reviewed, along with cutting-edge diagnostic and treatment options on the horizon.
Case Presentations
CASE 1
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 2
A 55-year-old man presents with “tearing” chest pain, blood pressure of 240/100 mm Hg, and generalized abdominal pain…
He has a pertinent past medical history of hypertension and was a heavy smoker for 20 years.
He has mild epigastric tenderness and an otherwise unremarkable exam.
Based on history, you wonder what the most appropriate workup and imaging for this patient would be…
CASE 3
A 48-year-old woman with Marfan syndrome is brought to the ED after a syncopal episode…
As you are evaluating her, she rapidly becomes more ill appearing and slower to respond to verbal commands.
Her heart rate is 140 beats/min and her blood pressure is 86/60 mm Hg. A portable chest x-ray demonstrates a widened mediastinal contour.
What is the reliability of this radiographic film finding? If a dissection is suspected, what can be done to temporize this patient’s condition?
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