Aortic Dissection

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60 yo come to ER with sudden onset of chest pain. he has pain between scapula also. history is of HTN, tobacco smoking. His blood pressure is 170/110

What is the initial test/best next step?

1- EKG
2- Chest X-Ray
3- CT Angio
4- MRI
5- TEE
6-TTE
7-Angiography
8-Chest CT


.....


Answer in the book of MTB step 2 is Chest X-Ray (as its the best initial test for Aortic dissection, and in MTB there is no option saying EKG (I Have added that myself to make my case) .... In my question, what would we choose??? EKG or CXR as best initial ... My opinion is EKG (Although the picture is VERY MUCH Aortic dissection, but EKG should be the first in my opinion in any case of chest pain) ...


Whats ur opinion?

 

[Fuzuli]

60 yo come to ER with sudden onset of chest pain...

Chest pain = EKG. If it's not already given in the stem of question, it's the first choice. Then you can tailor your next step according to the results of EKG.

A 60 year old man presents to ED with sudden onset of chest pain. His pain is located substernally and radiates to his back. His pertinent medical history reveals uncontrolled essential hypertension, smoking (30 pack-years), T2DM (uses metformin 2 g/day; HbA1c [3 mo's ago]: 7,2%) and COPD (uses tiopropium 1 puff/day) . His vitals are: T: 37,3 C, BP: 170/110 mm Hg, pulse: 120/min (right hand radial), RR: 24/min, SaO2: %89 (ambient air). In your physical examination, you notice a new early diastolic murmur in the upper left sternal border with an intensity of 2/6. After starting 1 L/min O2 with nasal cannula, you order a STAT cTnI, CK-MB and EKG, which shows signs of LVH and 1 mm ST depressions in leads V3, V4 and V5. Similar changes were present in his EKG taken 3 months ago. What is the best next step?

a) Order CXR
b) Give IV labetolol
c) Give 300 mg of non-enteric coated ASA orally
d) Give sublingual nitroglycerin
e) Give IV sodium nitroprusside

- One would be tempted to choose C, but giving aspirin to a suspected case of dissection could be catastrophic. Therefore, obtaining a CXR is appropriate

For the patient discussed above, a portable CXR is ordered. His CXR shows a widening of superior mediastinum. What is the best next step?

a) Order transthoracic echocardiography (TTE)
b) Order transesophageal echocardiography (TEE)
c) Order CT angiography
d) Order non-contrast CT of thorax
e) Order thorax MRI
f) Give IV morphine
g) Give IV labetolol

- Is CT the best, or is it MRI? Maybe echo? No to all - Pharmacology therapy should be initiated as soon as the diagnosis of aortic dissection is suspected. Therefore, IV labetolol is the correct choice here. After starting beta-blocker, the choice of test depends on hemodynamic stability of the patient and institution. If the patient is hemodynamically stable, CT, MRI, TTE, TEE or even aortography can be performed. If not, emergent TTE or TEE is more appropriate.

- BTW, instead of IV labetolol, IV nitroprusside + propranolol (or another beta-blocker) can be used for this patient as well.

After initiation of IV labetolol, you perform a TEE for this patient, which shows a type I (proximal) aortic dissection.

- For proximal aortic dissection (types I and II), emergency operation is required. For the distal type (type III), continuation of pharmacologic treatment is preferred.

 

[adagio]

Fuzuli, radiant as always, succinct, and straight to the crux ... Many thanks for your comprehensive reply ... Much appreciated

from the MTB book, Dr. Fischer says that accuracy is best with angiography, but i think that it has no place in diagnosis.

could the hemodynamic stability be a trick on the step 2 in your opinion? so that we would choose TEE when he is not stable rather than MRI?

 

[Fuzuli]

from the MTB book, Dr. Fischer says that accuracy is best with angiography, but i think that it has no place in diagnosis.

Use of CT, MR and echocardiography has all but replaced angiography. In fact, MR angiography is considered to be the gold standard now. Contrast-enhanced CT is close, and has certain advantages over MRA (quicker, so can be used in emergency settings, no ionizing radiation, more widespread use than MRA). If neither MRA or CECT can be done, then echocardiography can be performed.

could the hemodynamic stability be a trick on the step 2 in your opinion? so that we would choose TEE when he is not stable rather than MRI?

Sure. Just tweak the original question stem (make the patient hypotensive, with weak pulses and not responding to IV fluids) and ask what to do after administering IV beta-blockers.