54yo female presented to ED saturday 10am following 2/24 of central and epigastric CP.
CP associated w SOB and diaphoresis. Nil radiation. First episode of pain.
RF HT, HC, heavy smoker
nil RF DVT/PE
SL GTN with MAS led to a drop in BP, fentanyl 100mcg nil effect on pain. aspirin 300.
on transferring onto ED trolley complained of unsteady legs.
OE pale and diaphoretic
HR 74 BP 108/70 LA, 119/80 RA sats 92% afebrile
abdo soft and NT
LL normal tone and power
ECG: SR, anterolat t wave inv, 1/2mm STE V1-2
initial DD: ?LAD occlusion
also given unsteady legs: ? CP w neurology: need to exclude aortic dissection.
report: heart size is at the upper limits of normal. Mildly prominent aortic knuckle. Imaged lungs are clear. No large pleural effusion.
But maybe mediastinum is wide, L main bronchus does seem depressed.
CTA still to go ahead
Cardiology reg asked if we could do an ED echo for regional wall motion abnormalities/ dissection
pt still awaiting CTA due to multiple traumas.
pt stable. Ongoing CP.
ECHO done by ED: Parasternal long axis view that gives you palpitations!
Ascending aorta at least 5cm! anterior pericardial effusion with ?clot. RV collapse. At least she has a normal LV.
Abdominal longitudinal view of the aorta showing a dissection flap with independent motion.
Oliver Clowry who made the initial dx called. Vascular notified and came in 5mins. Theatre booked. CTA expedited.
In the meantime, a few more images for fun
Subcostal 4 chamber with aorta (probe tilted anteriorly) showing mural haematoma and dissection flap.
suprasternal view of aorta showing dissection flap
REPORT: Thoracic aortic dissection at the level of the aortic root extending into the L iliac artery. Associated small volume pericardial effusion.
Luckily most major vessel arose from the true lumen.
Pt went to theatre for grafting and remains in CCU today.
TTE is great for a type A dissection. However, type B dissections may not be seen, so cannot be excluded by a normal TTE in the ED. Of note, always remember to check the abdominal aorta for a dissection flap in the chest pain patient with a suspicious hx/ex.