American Journal of Emergency Medicine 33 (2015) 985.e1–985.e3

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Case Report

Early identification of an atypical case of type A dissection by transthoracic echocardiography by the emergency physician☆ Abstract Thoracic aortic dissection is a lethal disease, and emergency department diagnosis is limited by imperfect diagnostic testing and limited resources; however, this case report illustrates the nonspecific presentation of thoracic aortic dissection and the use of emergency physician use of transthoracic echocardiography with the addition of suprasternal notch views to help differentiate all-cause chest pain and aid in accurate diagnosis, as well as earlier surgical correction for best patient outcomes in cases of thoracic aortic dissection. Emergency physician-sonographer (EPS)–performed transthoracic echocardiography (TTE) has previously been dismissed as a diagnostic modality due to its perceived inferior sensitivity and specificity when compared with transesophageal echocardiography (TEE) [1]. However, aortic dissection is a life-threatening emergency that has best outcomes when identified early. The International Registry of Acute Aortic Dissection published a review of their case registry in 2000 and reported the findings of their 2-year case series which did not reinforce classic teaching of thoracic aortic dissection [2]. In the emergency department, physician diagnosis of thoracic aortic dissection is limited by imperfect tests and limited resources, with sometimes vague presentation. X-ray is an adjunct with poor sensitivity and specificity, and TEE is not regularly available. Computed tomographic angiography (CTA) is not always tolerated by patients due to hemodynamics, renal function, dye allergies, and so on. In the clinical case presented here, TTE helped make the diagnosis early in her initial evaluation. Aortic dissection results in a false lumen between the intimal and adventitial layers that can lead to subsequent organ dysfunction. Although uncommon, affecting 3 per 100 000 patients per year, thoracic aortic dissection is a lethal disease with a 2-week mortality of 75%, with 33% dying within the first 24 hours and 50% dying within the first 48 hours [2]. The elderly are most commonly affected occurring between the ages of 60 and 70 years, with men affected more than women, and hypertension being the most common predisposing factor. Genetic disorders, congenital diseases/syndromes, trauma, cocaine use, inflammatory/infectious diseases, and pregnancy are other predisposing factors [3]. Classic teaching of dissection is abrupt onset of severe, tearing chest, or midthoracic back pain with blood pressure deficits due to dissection near the subclavian artery [4]. Recommended testing modalities are TEE or CTA of the chest. Chest x-ray may be suggestive of dissection if there is a widened mediastinum, apical cap, or new pleural effusion; however, 10% of chest x-rays are

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read as normal. Computed tomographic angiography is the most common modality, with a sensitivity of 83% to 94% and a specificity of 87% to 100% [5,6]. Transesophageal echocardiography has the highest sensitivity and specificity at greater than 99% and 95%. Transthoracic echocardiography has a sensitivity of 78% to 87% for diagnosing a type A dissection, 29% to 40% in diagnosing a type B dissection, with smaller studies showing nearly 100% sensitivity [7,8]. Transthoracic echocardiography provides a quick method of diagnosis with good sensitivity and specificity, and with the addition of suprasternal notch views visualizing the intimal flap improving the diagnostic accuracy with sensitivity and specificity of 67% to 80% and 99% to 100% [9–12]. A previously, healthy 33-year-old woman without medical history presented to the emergency department with acute onset of epigastric, atraumatic, nonradiating pressure-like chest pain with associated nausea and diaphoresis starting 30 minutes prior to arrival. Patient was eating dinner and had a mild chest pressure that she mistook for indigestion, but progressed to severe chest pressure that finally prompted her emergency department visit. She had a triage performed electrocardiogram and was brought immediately back to a critical bed. She denied using tobacco, alcohol, or illicit drugs. Her initial vital signs were heart rate of 75 beats/min, blood pressure of 105/56 mm Hg in the left arm and 115/55 mm Hg in the right arm, respiratory rate of 18 breaths/ min, pulse oximetry of 94% on room air, and temperature of 99°F. On physical examination, she was visibly uncomfortable and diaphoretic; her cardiac examination did not reveal any murmurs, rubs, or gallops. Her lungs had scattered rales, but without wheezing or rhonchi. She had equal radial, femoral, and carotid pulses without deficits. She had a soft benign abdomen and was neurologically well without notable deficits. Her electrocardiogram was remarkable for inferolateral ST depressions as well as aVR ST elevation suggestive of subendocardial ischemia. Bedside EPS-performed TTE showed acute aortic regurgitation with blunted sinotubular junction and dilated aortic root (Video 1). A proximal suprasternal, short-notch view showed a posterior, aorta dissection flap (Video 2). No pericardial effusions, carotid artery dissections, or descending thoracic or abdominal aorta dissection were noted. Intravenous access was gained, blood work was drawn, portable chest x-ray (Fig. 1) was performed, and a cardiac surgeon was called for emergency surgery 15 minutes after the patient’s arrival to the triage area. Her blood work was remarkable for a lactate of 3.4 mmol/L and a slight leukocytosis. The surgeon ordered a computed tomographic scan of the chest en route to the operating room (Figs. 2 and 3). The computed tomographic showed the proximal aortic aneurysm as well as anterior, ascending aortic arch dissection flap to the level of the subclavian artery. During her 60-minute stay in the emergency department, the patient became more hypoxic and developed cardiogenic pulmonary edema which required 15 L by nonrebreather of supplementary oxygen to

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Fig. 1. CT Angiography of the ascending thoracic aorta with posterior wall dissection flap. Fig. 3.

maintain her oxygen saturations at 92%. She maintained mentation at all times, and a decision by the primary emergency physician was made to defer intubation so that she would not lose her respiratory drive. In the operating room, she had TEE showing complete circumferential dissection of the ascending aorta with intussusception of the intima. During her surgical repair, she had an aortic root aneurysm that circumferentiallly dissected the aortic valve and dissected the left and right coronary arteries at the ostia. She had reconstruction of the proximal portion of the hemiaortic arch, replacement of the aortic root with a mechanical valve, and reimplantation of the left and right coronary arteries. She was taken to the cardiac surgery intensive care unit and was extubated 5 hours postoperatively, discharged 3 days later, and was doing well at 1 year postoperatively. Her perioperative

Fig. 2. Sagittal CT Angiography showing dilation of the aortic root, as well as posterior wall dissection flap, correlating with suprasternal notch TTE view of the aorta wall flap.

and outpatient testing for genetic disorders, congenital syndromes, illicit drug use, inflammatory and infectious diseases, and pregnancy were found to be noncontributory. Emergency physician-sonographer performed TTE during the initial evaluation identified this patient’s acute, aortic valve rupture, and ascending aortic dissection, and reduced the time to surgical consultation and operative repair. Ascending, thoracic aortic dissection remains a lethal disease, with best mortality outcomes dependent on a timely diagnosis; however, emergency department diagnosis remains limited by the diagnostic modalities available. Both CTA and TEE are highly specific and sensitive methods, but these 2 are not always feasible for the patient or available. Patient history and physical examination are sometimes unclear, as seen in the case series by the International Registry of Acute Aortic Dissection group [2]. They found that most thoracic aortic dissections cases were elderly, white men with medical history of hypertension, with clinical presentations of abrupt onset of anterior chest pain that was described as severe or the worst ever pain with vital signs that were normotensive to hypertensive and few auscultated murmurs of aortic insufficiency or pulse deficits [2]. This case illustrates the use of EPS TTE with suprasternal notch views as a first-line modality during resuscitation that may expedite diagnosis and definitive therapy, as well as the rule-in of thoracic aortic dissection in the differential diagnosis for undifferentiated chest pain and dyspnea. This patient had ischemic cardiac chest pain without a classic history or physical examination findings leading to thoracic dissection as the primary diagnosis. In this case, possible delays for CTA diagnosis may have led to propagation of her aortic dissection and increased her risk for mortality. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ajem.2014.12.024.

S.E. Sparks et al. / American Journal of Emergency Medicine 33 (2015) 985.e1–985.e3

Acknowledgement We thank Karianne Sparks and Lindsey Solovey, RDMS for manuscript preparation. Scott Edward Sparks, MD Department of Emergency Medicine, Beebe Medical Center 424 Savannah Road, Lewes, Delaware 19958 Corresponding author. E-mail address: [email protected] Michael Kurz, MD, MS Department of Emergency Medicine, University of Alabama 619 19th Street South, Birmingham, Alabama 35233 E-mail address: [email protected] Doug Franzen, MD, M.Ed. Department of Emergency Medicine, University of Washington Medical Center, Box 356123, 1959 NE Pacific Street Seattle, Washington 98195-6123 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.024

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Early identification of an atypical case of type A dissection by transthoracic echocardiography by the emergency physician.

Thoracic aortic dissection is a lethal disease, and emergency department diagnosis is limited by imperfect diagnostic testing and limited resources;ho...
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