Rob Rogers gave a great lecture on aortic dissection at the NYU Med Ed conference yesterday. Here are the highlights:
-not common, but it is a killer
-classic presentation in 1/3
-aortic dissection can be subtle (isolated abdominal/extremity/back pain, syncope, hypotension, painless dissection) and you must think about the diagnosis
-as per John Elefteriades (chief of CT surgery at Yale), it is ‘almost the standard of care to miss this diagnosis’
-missed/delayed diagnosis will lead to malpractice
-however, cannot scan and admit everyone
-5 tips to decrease your chance of missing the dx:
1. symptoms above and below the diaphragm (ie: chest or neck pain + abdominal, pelvic, or lower extremity complaint)
2. “chest pain and …” syndrome: consider dissection when CP comes with additional complaints such as leg pain, weakness, neuro complaints
3. remember med mal clusters. scenarios that seem to recur in missed dissection cases include:
– acute severe (thunderclap) unexplained chest or back pain
– young patient with abdominal pain, hypertension and cocaine/vascular disease/smoking
4. remember young patients can have a dissection (ie. Marfan’s in writer of Rent)
5. patients who ‘look bad’ may be harboring a dissection
-consider suprasternal notch ultrasound to visualize proximal aorta
-chart should reflect your consideration of dissection, for example “equal pulses bilaterally, no murmur”
-negative d-dimer may not exclude dissection (intramural hematoma)
