How did your aortic dissection cases present?

[deleted836128]

My mind is racing because I’ve seen two aortic dissections in the last week and I feel like I could have easily missed them had I been in a rush and not prodded during the history. Makes me cringe thinking about it.

First one was a 69 year old with hypertension. Sudden onset of chest pain when watching TV. With no other symptoms at all. The thing that tipped me off is he didn’t want to move. Moving hurt his chest. Breathing hurt his chest. Me pushing on his chest made him wince. Just didn’t seem right. I thought, hmmm, CTA. He had a type I aortic dissection extending alllllll the way down to the iliacs.

The second one was scarier because it was in the fast track and the guy looked like a rose. Healthy dude in his early 40s. Waltzed in with his wife asking for an MRI for this left sided upper back pain he developed two days ago when picking up the phone. It was constant but it hurt to breathe. It was very reproducible; his wife circled the exact spot on his back with a pen and when I palpated here, he said “Ow!” Like the other guy, no other concerning symptoms like dyspnea, dizziness, belly pain, or numbness - EXCEPT just as I was pondering that maybe he just needs some Toradol, he said “my throat feels weird, too. It feels weird to swallow, like there’s something that gets stuck there.” He argues with me when I told him I was getting a CTA as he wanted an MRI to evaluate for herniated discs. He said “I know my body... I’ve had this before last year. It’s my back.” He told me his neurosurgeon wouldn’t see him without the MRI. WELL - got the CTA anyway, and he also had a type I with associated rupture... when I told him the news and that this is an emergency and that I was getting CT surgery on the line, he angrily told me to “hold on! Now it’s YOUR opinion that this is an emergency!”

The second one was more scary because if he hadn’t said the thing about the throat, and if I had bought his “I’ve had this exact same thing before and it’s a herniated disc!” I would’ve sent him home to die. Shudder.

Would love to hear your aortic dissection stories. How did they present?

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[Dr Mantis Toboggan]

I’ve found the opposite, most of my dissection patients can’t get comfortable no matter what position they’re in and the pain is not really reproducible, they almost have a constant writhe. They are also generally quite hypertensive. Most of my mine have been type 2.

My mind is racing because I’ve seen two aortic dissections in the last week and I feel like I could have easily missed them had I been in a rush and not prodded during the history. Makes me cringe thinking about it.

First one was a 69 year old with hypertension. Sudden onset of chest pain when watching TV. With no other symptoms at all. The thing that tipped me off is he didn’t want to move. Moving hurt his chest. Breathing hurt his chest. Me pushing on his chest made him wince. Just didn’t seem right. I thought, hmmm, CTA. He had a type I aortic dissection extending alllllll the way down to the iliacs.

The second one was scarier because it was in the fast track and the guy looked like a rose. Healthy dude in his early 40s. Waltzed in with his wife asking for an MRI for this left sided upper back pain he developed two days ago when picking up the phone. It was constant but it hurt to breathe. It was very reproducible; his wife circled the exact spot on his back with a pen and when I palpated here, he said “Ow!” Like the other guy, no other concerning symptoms like dyspnea, dizziness, belly pain, or numbness - EXCEPT just as I was pondering that maybe he just needs some Toradol, he said “my throat feels weird, too. It feels weird to swallow, like there’s something that gets stuck there.” He argues with me when I told him I was getting a CTA as he wanted an MRI to evaluate for herniated discs. He said “I know my body... I’ve had this before last year. It’s my back.” He told me his neurosurgeon wouldn’t see him without the MRI. WELL - got the CTA anyway, and he also had a type I with associated rupture... when I told him the news and that this is an emergency and that I was getting CT surgery on the line, he angrily told me to “hold on! Now it’s YOUR opinion that this is an emergency!”

The second one was more scary because if he hadn’t said the thing about the throat, and if I had bought his “I’ve had this exact same thing before and it’s a herniated disc!” I would’ve sent him home to die. Shudder.

Would love to hear your aortic dissection stories. How did they present?

 

[GatorCHOMPions]

70s y/o F - cleaning the bathroom with strong chemicals and had syncope. She reported a little "dizziness" of the elderly variety. Stone cold normal vitals (HR 60s, SBP 120s). Only thing that tipped me off was a couple hours into ED stay she had a painful bloody BM. Bedside abdominal US showed a dissection flap. CTA showed a type-A all the way down to the iliacs.

 

[southerndoc]

I work in a very busy ER (150,000/year) that is a tertiary care center. I've seen numerous dissections both primarily as well as transfers. I've seen all kinds of presentations -- young with ripping pain that can't sit still, little old granny with exertional chest tightness who was found to have a type A dissection only by a CTA ordered due to an elevated d-dimer, etc. One of my colleagues just had someone who had NO chest, back, or abdominal pain and only presented with right leg pain. He had a cold leg. Vascular happened to be in the ER, so he told them about the guy before he went to CT. Vascular went to CT with him and had booked him to the OR when they saw the aortic dissection in his abdomen. They added a CTA chest and saw a type A dissection. Guy coded shortly after his CT. Scares me when he told the story -- no chest, back, or abdominal pain!

 

[deleted859535]

Have also had atypical presentations. Scary, but that's the world we live in. They will get missed if early and atypical enough.

Document a good note with what you have and know at the time, and image if something doesn't seem right. That's all you can do.

 

[RuralEDDoc]

Have found 3. Two with classic presentation and were easy pickups - patients looked horrible and had classic pain. Third was atypical - 60yo M, slow onset pressure like mid chest pressure, non radiating, mild shortness of breath. Normal BP. EKG normal. Scanned him looking for PE as pain became pleuritic three hours into ED stay and nitro didn’t help pain initially. Type A dissection extending to iliacs (found that on the follow up scan after the CTA looking for PE caught the initial aortic component).
A partner of mine unfortunately missed one on a patient presenting with sudden onset severe chest pain and severe headache. He was focused on the headache and scanned the head only. BP was through the roof. Patient died of aortic dissection. It’s important to remember that the aorta can dissect into the carotids and cause headache and stroke. Unfortunately mortality at that point is extreme so not sure catching it initially would have made any difference, but still, gotta keep a broad differential and think of life threats first particularly the organ systems that cross various body parts (eg vascular system).

 

[RustedFox]

45 year old giant.
Picked up a drum of fryer oil at work.
Mid-thoracic back pain.
Better after toradol/flexeril. "Thanks, Doc!"
Discharged. I was a senior resident at the time.

"Look, amigo; if anything changes - you get right back here. We will take care of you."
"You betcha, Doc! You da man!"

1 shift later.

"Pain is back and is worse than ever."
Can't sit still.
Type B dissection.
Fixed.

He actually said to me: "I remember; you said if anything changed to get right back here, so I did."

 

[Cinclus]

First was a middle-aged guy who didn't really see a doctor, so no known PMH. He was hanging out with friends when his arms started to feel weak and numb - came to the ED for this, then started to feel like he was dying, couldn't breathe, etc. His BP was through the roof. Type A, had to fly him out (not a very long flight - one city over, essentially). Guy survived the surgery and had mild, persistent neurological deficits. Actually saw him again when he returend to the same ED for chest pain a few months later, which is how I knew he survived. As soon as I saw his name on the board, I was in the room, haha. He was OK the second time.

Second was a woman in her mid-40's, no h/o HTN, only real PMH was that she was a pretty heavy smoker. This was at a different hospital. BP was quite normal in the ED. Came in with severe chest pain with radiation to back and abdomen and just looking quite ill, extremely uncomfortable. Type A dissection that extended all the way to the iliacs. That CT was horrifying. She just kept looking more and more like death as we waited for the chopper to come fly her out to a CT surgeon (flew within the same city). She made it to the OR, but she did not survive surgery. I actually searched for an obituary a few weeks later, and that's how I knew she died.

I guess I haven't seen too many yet, which is fortunate. I remember both of these people's faces and names. I remember the woman's young adult daughter crying and holding her hand while the patient kept looking worse and worse, while I placed an arterial line just before the flight guys took her. These are tough to forget.

 

[AlmostAnMD]

Last one I had was a nurse-initiated stroke alert, which usually gets whisked right by me and to CT from triage.

Got a call from stroke neurologist non-con was negative.

So I went to see the patient once he was available to see and found a bp 60/40 and he could only move his R arm. L arm, BLE completely paralyzed.

Stroke alert on someone with type A dissection looooool

 

[Tenk]

Dissections are one of the reasons I usually use iv contrast in old people with back pain. Had one recently. Zero chest pain. Type B all the way to the illiacs.

Dissections are dumb.

 

[southerndoc]

Last one I had was a nurse-initiated stroke alert, which usually gets whisked right by me and to CT from triage.

Got a call from stroke neurologist non-con was negative.

So I went to see the patient once he was available to see and found a bp 60/40 and he could only move his R arm. L arm, BLE completely paralyzed.

Stroke alert on someone with type A dissection looooool

You'd be surprised at the number of dissections that get called stroke alerts (granted, I work in a comprehensive stroke center). Lots of dissections extending to the carotids cause strokes.

 

[pkwraith]

I had a dissection on a stroke. CT Angio head and neck picked up the top of the aortic arch dissection. Problem is they actually had a hemorrhagic stroke too.
Didn't make it as neither neurosurgery or CT surgery could do anything because of the other problem.

I also had a fun Board type patient who had a disssection, was anticoagulated on warfarin, and was a Jehovah's witness.

 

[MechEDoc]

1) "I have neck pain radiating to my head, a weird headache and 220/110 is normal for me". "I'm also allergic to all anti-hypertensives and my homeopath has reassured me that my vital forces are normal". Normal exam, BP 120/80, ~5 min later, tamponade, seizure, cardiac arrest.
2) "I had a weird jaw pain, funny feeling by my eyes, but now only have whooshing in my ears". Type 1 dissection without pericardial involvement.
3) "I have heartburn like, mild chest pain". CXR normal, ECG with STEMI, dx changed in the cath lab.
4) "I have a sharp, nagging pain by my scapula for several weeks". Aortic dissection, progressed over about 6 weeks before death while on palliative care.

 

[MechEDoc]

Dissections are one of the reasons I usually use iv contrast in old people with back pain. Had one recently. Zero chest pain. Type B all the way to the illiacs.

Dissections are dumb.

Age 50 and up, if they have back pain, I ultrasound the aorta.

 

[SamtheWise]

Mesenteric ischemia, dissections and bad NSTEMIs are the most humbling diagnoses. You've gotta either accept you're going to test everyone for everything all the time, or miss a few. I dunno what the right answer is.

 

[ThoracicGuy]

Have found 3. Two with classic presentation and were easy pickups - patients looked horrible and had classic pain. Third was atypical - 60yo M, slow onset pressure like mid chest pressure, non radiating, mild shortness of breath. Normal BP. EKG normal. Scanned him looking for PE as pain became pleuritic three hours into ED stay and nitro didn’t help pain initially. Type A dissection extending to iliacs (found that on the follow up scan after the CTA looking for PE caught the initial aortic component).
A partner of mine unfortunately missed one on a patient presenting with sudden onset severe chest pain and severe headache. He was focused on the headache and scanned the head only. BP was through the roof. Patient died of aortic dissection. It’s important to remember that the aorta can dissect into the carotids and cause headache and stroke. Unfortunately mortality at that point is extreme so not sure catching it initially would have made any difference, but still, gotta keep a broad differential and think of life threats first particularly the organ systems that cross various body parts (eg vascular system).

That's happened at our hospital several times over the last couple of years. Had a carotid duplex that ended up showing a dissection. They got shipped out stat.

 

[deleted859535]

Mesenteric ischemia, dissections and bad NSTEMIs are the most humbling diagnoses. You've gotta either accept you're going to test everyone for everything all the time, or miss a few. I dunno what the right answer is.

Context and documentation.

Not really speaking to you but just in general, I'd submit that sometimes, it's not the final diagnosis so much as it is what you can justify and defend as of your exam.

If you don't do every test on every patient, as you shouldn't, you're going to miss something at some point.

The vague scapula pain with absolutely no other signs and symptoms of a dissection, which may or may not have had a quasi-musculoskeletal portion of presentation? Could be lots of things. Frequently those folks get a good lab/CXR/EKG work up at more elderly ages. And equally frequently, some charted reflection of dissection in the differential -- the pertinent negatives, equal pulses, "considered such-and-such but", etc.

Yes, we all know that dissections are sometimes sneaky bastards. But if it's subtle enough, or with enough of a reasonable red herring, you know what the standard of care is?

To miss it.

 

[Interpolfanclub]

Context and documentation.

Not really speaking to you but just in general, I'd submit that sometimes, it's not the final diagnosis so much as it is what you can justify and defend as of your exam.

If you don't do every test on every patient, as you shouldn't, you're going to miss something at some point.

The vague scapula pain with absolutely no other signs and symptoms of a dissection, which may or may not have had a quasi-musculoskeletal portion of presentation? Could be lots of things. Frequently those folks get a good lab/CXR/EKG work up at more elderly ages. And equally frequently, some charted reflection of dissection in the differential -- the pertinent negatives, equal pulses, "considered such-and-such but", etc.

Yes, we all know that dissections are sometimes sneaky bastards. But if it's subtle enough, or with enough of a reasonable red herring, you know what the standard of care is?

To miss it.

All true. Had a guy in his early 30s a year ago. Heavy smoker, morbid obesity, extreme HTN in ER with back pain and I thought "I think he's dissecting." Nurses thought I was nuts. Began the workup and then he developed hip pain and I knew I was right. Got a big arch stent. Another guy came in with back pain like his "kidney stones" but something just didn't feel right so I chased it. Still see him on occasion. Agree with everyone else, sometimes you're just going to miss them. You can't work everyone up for everything all the time despite what lawyers think. Be nice to people, document, make them feel comfortable with coming back. If it is their 2nd or 3rd visit for the same complaint better think hard.

 

[lymphocyte]

My first one was by accident.

I took the pager off a resident on night float so he could get a quick nap. Got a page from the coronary care for some Tylenol. Patient had back pain. Nurse, who is good, wasn't concerned. Quick read of the notes: small trop leak, new AF, presented with pre-syncope, chest pain, treated as NSTEMI, history of osteoarthritic back pain -- I almost didn't see her, just okay to the Tylenol.

But curiosity got the better of me. I peaked at the CXR. Massively widened mediastinum. I looked at the nursing triage note -- intially had abdominal pain and then had chest pain. I then asked the patient -- who said she never had back pain this bad before -- if there was one word to describe the kind of pain she felt when the pain started, would that word be "tearing"? She nodded her head. Apparently the XR got missed on handover. I ended up wheeling her down to CT myself, pushing labetalol along the way.

 

[RoyBasch]

The last 3 that I can remember:

Cardiac arrest with ROSC in an elderly patient. Type A dissection with pericardial effusion and tamponade, CTS declined to operate and they recommended palliative care to family.

Undifferentiated altered mental status in an elderly patient. Type A dissection with BL cartoid involvement causing bihemispheric stroke, CTS declined to operate and they recommended palliative care to family.

Chest and back pain in a middle age patient. Type B dissection. Got an EVAR. --that one was easy.

It's a tough diagnosis. Stay frosty.

 

[bravotwozero]

The one case I saw post residency came too late.

Thanksgiving day, I'm on shift.

EMS call for 50 something year old with back pain going towards legs, syncope, hypotension. Already, alarm bells are going off in my head.

Patient comes in, alert and taking, BP better after fluids. I get a CTA right away, dissection from the aortic root right down to the iliacs.

Frantically, I'm contacting the transfer center and trying to life flight this guy outta here, as we don't have CT surgery.By the time the flight crew gets there, his belly expands rapidly, and he arrests. Never got him back.

His whole family, including wife and kids were at the bedside.

Will never forget that one.

 

[USCDiver]

Had one a few years ago, 40ish yo obese guy complaining of severe abdominal pain, diffusely tender, writhing on the bed, but SBP 140s. I'm thinking more along the lines of perfed ulcer/peritonitis so sent him for a CT Abd/Pel. Rads calls like 1 minute later saying to send him back for a CTA chest!

 

[SamtheWise]

Context and documentation.

Not really speaking to you but just in general, I'd submit that sometimes, it's not the final diagnosis so much as it is what you can justify and defend as of your exam.

If you don't do every test on every patient, as you shouldn't, you're going to miss something at some point.

The vague scapula pain with absolutely no other signs and symptoms of a dissection, which may or may not have had a quasi-musculoskeletal portion of presentation? Could be lots of things. Frequently those folks get a good lab/CXR/EKG work up at more elderly ages. And equally frequently, some charted reflection of dissection in the differential -- the pertinent negatives, equal pulses, "considered such-and-such but", etc.

Yes, we all know that dissections are sometimes sneaky bastards. But if it's subtle enough, or with enough of a reasonable red herring, you know what the standard of care is?

To miss it.

Yeah I completely agree, sometimes you're just unlucky and r/o ACS in a patient with mild hypertension, equal pulses, normal mediastinum and gradual onset pain, and send home a dissection. I always try and discuss the fact that there is some diagnostic uncertainty and use that to lead into good return precautions, but at a certain point, what can you do? CTA everyone? You'd do way more harm than good.

 

[dchristismi]

Oy, I've had a bunch. Here are 3 off the top of my head.

Most recent was a 87 yo lady with sudden pain while eating breakfast. Pain resolves. but OOP... happens again. Every time she cries out, it rips a little more. Classic pain, get the CT and sure enough, there's the beginning of the tear at the root. She tells me point blank that she knows she isn't going to live to 88, and that it's ok. She calls her daughter and basically says good bye. CT surg walks in the room and BAM, she falls over dead. No agonal breaths, no bradycardic beats, just boom, dead. She was ok with it, I and my staff weren't.

Had one present as a stroke alert, couldn't move her arm. Of course she goes straight to CT. When I see her, I automatically went for the pulse and... she has a pulseless R arm, which is why she can't move it. EMS mentions that she said her chest hurt at one point, but they were definitely fixated on stroke. Told her husband to kiss her, and back to the scanner, and it's a massive dissection out the axillary and up the carotids. As I'm running back to the room paging CT surg, they call a code overhead and sure enough, it's her. So we go through it, and about 5 minutes in, she starts pouring blood out of her nose and mouth. I still don't know what the heck perfed... it was something out of a horror movie. Her poor husband watched the whole thing.

And had another present at a STEMI... but looked not quite right. Had that bolt-upright look of a pneumothorax, just not right. Classic ST changes. Cards wants him on their table, I saw a wide-ish mediastinum. The cardiologist is chewing me out in the scanner ("see, there's no perfusion... this guy needs to be on my table!") and then we see it. He whips out his cell phone, calls CT surg, bops me on the shoulder with a nod of the head and strides out. I don't remember what happened to him.

And there are plenty more. This diagnosis (IMHO) more than any other sears into our souls.

 

[drmwvr]

Type B dissection.
Fixed.

What do you mean, fixed?

 

[RustedFox]

What do you mean, fixed?

CT surgery fixed it.
Somehow.
I don't pretend to know how.

 

[drmwvr]

CT surgery fixed it.
Somehow.
I don't pretend to know how.

Just mentioned it because they're more commonly medically managed, although now with the advent of endovascular repair, more are considered for the OR at some centers...but that's a more relatively recent thing and not at all centers with that capability, afaik....

 

[RustedFox]

Just mentioned it because they're more commonly medically managed, although now with the advent of endovascular repair, more are considered for the OR at some centers...but that's a more relatively recent thing and not at all centers with that capability, afaik....

Full Disclosure:

I have no idea what happened to the patient after "Admit: Consult CT surgery" other than I saw him several months later in the ER for a non-related complaint. I will never forget this giant man and his gentle manner. "Doc. They fixed me all up! Thank you so much."

This was 2012, pretty sure.

 

[thegenius]

Mesenteric ischemia, dissections and bad NSTEMIs are the most humbling diagnoses. You've gotta either accept you're going to test everyone for everything all the time, or miss a few. I dunno what the right answer is.

I hear ya. The right answer, I believe, is you are gonna miss a few.

The health care system would come crashing to a halt if you scanned every single chest pain. Every ER would be on divert.

You do your best.

One thing I do do...is I more often order dissection studies as you will pick up major PE's too. However a properly timed PE study basically misses the aortic arch.

 

[WheezyBaby]

Context and documentation.

Not really speaking to you but just in general, I'd submit that sometimes, it's not the final diagnosis so much as it is what you can justify and defend as of your exam.

If you don't do every test on every patient, as you shouldn't, you're going to miss something at some point.

The vague scapula pain with absolutely no other signs and symptoms of a dissection, which may or may not have had a quasi-musculoskeletal portion of presentation? Could be lots of things. Frequently those folks get a good lab/CXR/EKG work up at more elderly ages. And equally frequently, some charted reflection of dissection in the differential -- the pertinent negatives, equal pulses, "considered such-and-such but", etc.

Yes, we all know that dissections are sometimes sneaky bastards. But if it's subtle enough, or with enough of a reasonable red herring, you know what the standard of care is?

To miss it.

Completely agree but just to supplement, if you're an otherwise presumably astute clinician not ordering dumb **** on everyone, but you get that spidey sense on somebody, that pit in your stomach feeling that some thing's off, despite all objective evidence to the contrary, I'm all aboard spinning those people erryday (or doing whatever "nonindicated" testing you feel is warranted). It's not 100% by any means but there can certainly be subconsciously recognized factors generating that ick feeling and imo its worthwhile overtesting patients that generate that ick factor

 

[TooMuchResearch]

My only experience has been that vascular, sometimes in concert with CT surgery, fixes them, generally in an endovascular fashion I think.

Just mentioned it because they're more commonly medically managed, although now with the advent of endovascular repair, more are considered for the OR at some centers...but that's a more relatively recent thing and not at all centers with that capability, afaik....

 

[TooMuchResearch]

That ick factor is your experience telling you something, even if you can best describe it as ick.

Completely agree but just to supplement, if you're an otherwise presumably astute clinician not ordering dumb **** on everyone, but you get that spidey sense on somebody, that pit in your stomach feeling that some thing's off, despite all objective evidence to the contrary, I'm all aboard spinning those people erryday (or doing whatever "nonindicated" testing you feel is warranted). It's not 100% by any means but there can certainly be subconsciously recognized factors generating that ick feeling and imo its worthwhile overtesting patients that generate that ick factor

 

[RustedFox]

Completely agree but just to supplement, if you're an otherwise presumably astute clinician not ordering dumb **** on everyone, but you get that spidey sense on somebody, that pit in your stomach feeling that some thing's off, despite all objective evidence to the contrary, I'm all aboard spinning those people erryday (or doing whatever "nonindicated" testing you feel is warranted). It's not 100% by any means but there can certainly be subconsciously recognized factors generating that ick feeling and imo its worthwhile overtesting patients that generate that ick factor

Yep.

Its that "spider sense" that OtherDocs just don't have.

I said recently during a trip to the med-exec committee that "75% of what we do in the ER is 'defense against the dark arts'."

 

[southerndoc]

Had a type A dissection transferred in today. EMS said his sats were dropping 3 mins from hospital. So instead of going to the OR, he went into a trauma bay. I tubed him, OR team came down and was about to wisk him away when he coded. They took him to the OR doing chest compressions (!!). Of course he didn't make it.

 

[TooMuchResearch]

Hmm, I'm curious what their plan was. Can they be saved once they've died (coded) from the dissection?

Had a type A dissection transferred in today. EMS said his sats were dropping 3 mins from hospital. So instead of going to the OR, he went into a trauma bay. I tubed him, OR team came down and was about to wisk him away when he coded. They took him to the OR doing chest compressions (!!). Of course he didn't make it.

 

[Epinephreus]

First dissection in residency. 40F, healthy, pw seizure like activity. She gets code stroke'd even though she mostly returned to baseline and I was pretty convinced she was a Todd's, CTA neck on the stroke protocol picked up a dissection flap in the carotid coming from a type A dissection. No pain. I still get nightmares about this case.

 

[bravotwozero]

Hmm, I'm curious what their plan was. Can they be saved once they've died (coded) from the dissection?

I don’t see how. If the dissection is bleeding out and now you’re doing chest compressions, it would seem all that you’re going to do is make the dissection worse...


Sent from my iPhone using Tapatalk

 

[Groove]

Weird, I really don't have many cases where I find acute dissections on people that are asymptomatic or are there for completely atypical complaints. If I do, it's usually a chronic dissection with intramural thrombus that is just incidentally found on CT. Most of my acute ones are relatively obvious. Chest pain with hypertension always alerts. Chest pain/HTN with neuro complaints (especially stroke patients who have vague chest and/or abdominal pain). Pts with back or chest pain and just can't get comfortable, etc.. I also bolus time some of my CTAs to look for both PE and aorta. I usually have to tell the radiology tech to time the study appropriately and/or use extra contrast. Also, call me old school but I still look at mediastinal width on CXR and end up CT'ing a few pt's with CP and wide mediastinum and/or really ectatic aortas. Most are normal but occasionally I'll find something (usually NOT a dissection, but more like a small aortic aneurysm, etc..)

I don't think I've ever had a dissection that did not have a component of chest/back or belly pain.

One of the most impressive ones was a stroke pt in residency who had one of our new neurology attendings at the bedside about to push TPA. Our chair (used to be research director and wickedly smart dude) was standing at the doorway with head cocked, brow slightly furrowed as the pt started complaining of some vague belly discomfort and pooped himself. He goes "Dr. Neurology, please do not push that TPA. CTA that pt and rule out dissection before proceeding." Neurologist looks confused and frustrated. We get the pt to CT and he had a huge dissection A/B all the way down to the iliacs.

 

[drmwvr]

Hmm, I'm curious what their plan was. Can they be saved once they've died (coded) from the dissection?

No. Same goes for ruptured AAA.

 

[southerndoc]

Hmm, I'm curious what their plan was. Can they be saved once they've died (coded) from the dissection?

Not sure honestly. The guy unfortunately died. Maybe he was thinking if it dissected into his coronaries (you could see ST elevation on monitor) that he developed a tamponade?

 

[SpacemanSpifff]

... Would love to hear your aortic dissection stories. How did they present?

Middle aged guy brought in unresponsive by EMS, had been complaining of back pain to friends and the squad was concerned about cocaine use. JVD prior to intubation. Bedside TTE after intubation with a dilated aortic root, flap in the proximal aorta, ran the probe through the abdomen to find intra-abdominal extension with thrombus all the way down.

 

[deleted950463]

Mesenteric ischemia, dissections and bad NSTEMIs are the most humbling diagnoses. You've gotta either accept you're going to test everyone for everything all the time, or miss a few. I dunno what the right answer is.

it can seen like in academic and in training everyone’s all about doing the least possible and use scores/algorithm/physical exam to prevent “unnecessary” imaging or tests.

however real life don’t read books. There are benign appearing patients who are deathly ill and benign appearing lesions in imaging that are cancerous.

honestly this young rad attending went from “lets observe this super benign appearing lesion that is do not touch” to biopsying everything requested. I think in real life, as long as the spectre of legal action is there, there isn’t a “do not touch” lesion and it’s honestly safer to test and image with an incredibly low threshold.

 

[SirGecko]

it can seen like in academic and in training everyone’s all about doing the least possible and use scores/algorithm/physical exam to prevent “unnecessary” imaging or tests.

however real life don’t read books. There are benign appearing patients who are deathly ill and benign appearing lesions in imaging that are cancerous.

honestly this young rad attending went from “lets observe this super benign appearing lesion that is do not touch” to biopsying everything requested. I think in real life, as long as the spectre of legal action is there, there isn’t a “do not touch” lesion and it’s honestly safer to test and image with an incredibly low threshold.

Dude you should take a look at the way you talk. “This young rad attending?” What young rad attending? It sounds like you are trying to pretend to be a radiologist. Is that what you are trying to do? If it isn’t I would take a look at the way that you type things.

On the subject of the thread I had a chest X-ray as a first year radiology resident with a hella widened mediastinum coming from an outpatient clinic working a guy up for hypertension. Talked to the ordering provider, no chest pain, just working up hypertension. Guy was transferred to the ER to get a CT and he had a huge type A dissection nearly down to his illiacs excluding his left kidney in the false lumen. Apparently on interview (by the ER docs) the guy remembered having dissection type pain a couple of years ago and never had it worked up but it went away.

 

[TooMuchResearch]

I guess so, I've just always been under the impression (and so far still am) that it's not a winnable case.

Not sure honestly. The guy unfortunately died. Maybe he was thinking if it dissected into his coronaries (you could see ST elevation on monitor) that he developed a tamponade?

 

[deleted859535]

it can seen like in academic and in training everyone’s all about doing the least possible and use scores/algorithm/physical exam to prevent “unnecessary” imaging or tests.

however real life don’t read books. There are benign appearing patients who are deathly ill and benign appearing lesions in imaging that are cancerous.

honestly this young rad attending went from “lets observe this super benign appearing lesion that is do not touch” to biopsying everything requested. I think in real life, as long as the spectre of legal action is there, there isn’t a “do not touch” lesion and it’s honestly safer to test and image with an incredibly low threshold.

Again. The idea of your post isn't wrong. But your belief that you know more than you do with vague comments of being not a med student is dangerous and a bit comical.

 

[deleted950463]

I find it hilarious that everytime I post something people seem to absolutely lose their mind And just side track the thread.

But back on topic of this thread. You can just ask rad at your shop to develop a double r/o protocol if not already done. Some of those involves injection of two boluses so you will opacify both aorta and pulmonary artery. You do end up giving a bit more contrast but for healthy folks it’s not a huge deal.

 

[TooMuchResearch]

My understanding is that it's because you misrepresent yourself and your credentials

.

I find it hilarious that everytime I post something people seem to absolutely lose their mind And just side track the thread.

But back on topic of this thread. You can just ask rad at your shop to develop a double r/o protocol if not already done. Some of those involves injection of two boluses so you will opacify both aorta and pulmonary artery. You do end up giving a bit more contrast but for healthy folks it’s not a huge deal.

 

[VA Hopeful Dr]

My understanding is that it's because you misrepresent yourself and your credentials

.

You are correct. This all started in the Critical Care forum.

The thread this poster started was titled:
What’s one thing you wish your IR guys/gal know?


The original post was this:

"As title. IRs deal with a lot of ICU pts. Are there one or more things you wish to have us know about critical care?" <emphasis mine>

 

[deleted950463]

You are correct. This all started in the Critical Care forum.

The thread this poster started was titled:
What’s one thing you wish your IR guys/gal know?


The original post was this:

"As title. IRs deal with a lot of ICU pts. Are there one or more things you wish to have us know about critical care?" <emphasis mine>

oh sure, I can see that’s misleading from that typo coming from a student who’s interested in the field.

 

[BoardingDoc]

oh sure, I can see that’s misleading from that typo coming from a student who’s interested in the field.

Yeah. Typo.

I tell med students the best specialty is one that gives you the MOST option.

think internal medicine. You can practice like a surgeon with interventional cards/advanced GI or you can live a full outpt lifestyle. You can live anywhere. Hell you can pinpoint the neighborhood in NYC almost.

Radiology is also something similar. As of right now you can practice a near surgical lifestyle to just read at home in your PJs.

Rads also allow 100% geographical flexiblity if you are willing to do telerad.

from an IR prospective Y90 really is only used for things that are at least decently hypervascular. One can consider radiation segmentecomy but even then I am concerned that our brachytherapy y90 particles just aint gonna penetrate this whole thing.

if this is in my institution, I would be happy to place as many ficiduals as you need for you to zap this thing.

this is also a bit too big for ablation.

this is one thing that I will bounce to radonc first line if I see in tumor board. Y90 mapping if everyone extremely onboard. Will not treat if mapping shows any hetergenity in the uptake in that thing. Y90 just really isnt done for pancreatic CA mets.

This is a practicing rad. I can tell you right now I use zero physics in my day to day work.

My day to day is either plumbing related / handskill / craft / surgery or looking at pictures and describe them.

I don't think that counts as a typo so much as deliberate fraud.


To bring this thread back to its original point:
Last dissection presented as a syncopal episode in an older guy. LOC after a BM. Brought in by his daughter. Guy was rather demented, couldn't give much hx. Seemed fine at the time. Daughter said he had a hx of vasovagal syncope. Seemed similar. Exam entirely benign. Got basic labs. Trop was something like 0.08 with normal renal function. EKG benign. Go back in to explain it looks like it might be cardiac and she tells me he has started complaining of bad abd pain. Now diffusely tender entire abd. Stat CT shows type B dissection infrarenal to iliacs with an area that has clearly ruptured. Vascular signed off. Admitted as CMO.