A 45 year old previously healthy man comes to the Emergency department with severe painin the chest. He describes it as th eworst pain of his life and says it is like something being ripped iside. The location of the pain has changed since it started. It has moved from the lower part of his central chest to the back of the thorax. He is restless and is hooked up to the EKG machine. O2 is started and an IV is established.

On examination, you hear a diastolic murmur and request a Chest Xray.

Which is the next step in the managemment of the patient?

1. Immediate pain relief using Demerol (Meperidine)

2. Aspirin

3. Sublingual nitroglycerine

4. CT of the chest

5. Stat cardiology referral

The answer is 5. This patient has more than k=likely got an aortic dissection in the chest. Demerol is a sympathomimetic besides being a painkiller. This will make the heart faster.

AR is a well known association of thoracic aortic dissection. Aspirin is contra-indicated as this will worsen the patient.

S/L nitroglycerine is also going to increase the shearing effect of each pulse.

CT of the chest is important but TEE is investigation of choice and this situation demands a stat cardiology consult. Do not be afraid in practice to do this either - of the fear that the fellow or consultant will be upset. If he does - it is his problem. The situation is life threatening and must be investigated immediately.

CARDIOLOGY

Select the best diagnostic test for suspected Thoracic aortic dissection.

Explanation:

TEE (trans esophageal echocardiography) is the preferred test during an emergency. MRI is the preferred test in a non emergency situation. Once the diagnosis is confirmed - an MRA or angiogram would be done. If in a hurry and TEE is not available, CT is a good screening tool.

Although the guidelines give the above mentioned algorithm, an MRI is >95% sensitive and >95% specific - but in the emergency situation may not be available.

Similarly Ultrasound is the investigation of choice to screen for AAA/AA Rupture

Question based on the above could test your ability to diagnose the conditions and or the above fact.

Clinical features are

Severe pain - shearing tpe that is travelling

Difference in blood pressure between the two upper limbs in case of thoracic and between upper

Aortic regurgitation murmur

Difference in the pulse strength between the two upper limbs

H/O HTN