Hx: A 50 yo woman arrives in the ED complaining of “eating bad Mexican food”. She was at a nearby restaurant when she experienced abdominal pain, but feels better and feels “silly” for being in the ED. Pressing for more, she relates sudden onset of mid abdominal pain in the epigastrum that moved to her chest, then back down to her lower abdomen. It was severe and sharp but then resolved shortly before arrival. On review of systems, she happens to mention that she lost vision in her left eye briefly during the episode. Currently, she has no complaints. No nausea, vomiting, fever, or recent illnesses.
• Vital Signs: Pulse 55, BP 80/50, RR 12, Temp 98.6, O2 sat 100% RA
• General: tall, 50 yo woman in no distress, laying in stretcher.
• HEENT: normal
• Resp: clear bilaterally
• Cardiovascular: regular rate, no murmurs, normal pulses peripherally.
• Abdomen: soft, no tenderness or masses
• Extremities: warm with good pulses
• Neuro: Awake and oriented x4, normal strength and sensation and cranial nerves.
• Vasovagal hypotension
• Pregnancy, ectopic rupture
• Occult MI/ACS
• Aortic Dissection
• On seeing the BP on the monitor, a second measurement is taken on the opposite arm and reads 110/60
• IV is placed, cardiac monitor shows normal sinus bradycardia
• Stat CT angiogram of the aorta (chest and abdomen) reveals a type A aortic dissection involving the entire length of the aorta but not the cervical vessels. There is involvement of the left subclavian artery.
• Laboratory evaluation is completely normal.
• The patient is normotensive and not tachycardic.
• She is emergently taken to the operating room for aortic valve replacement and aortic endograft.
• The patient does very well post operatively and suffers no complications.
Discussion: Aortic dissection is typically described as a tearing, severe pain assocaited with hypertension. However, up to 25% of type A dissections can present with hypotension acutely. Typical medical treatment is management of pain, and aggressive control of blood pressure with IV esmolol in order to reduce left ventricular “velocity” of contraction, and IV nipride to manage hypertension. Patients require emergent operative repair and dissection extension past the aortic root may require valve replacement in addition to aortic grafting.
This case highlights the challenge we encounter in medicine when patients do not present in the “classic” manner. This patient’s complaints had resolved and her pain radiating to chest, with transient loss of vision in one eye, could have easily been dismissed as transient hypotension due to a vagal episode. Had her initial blood pressure been measured in her right arm a second measurement in the left may not have ever occurred, the blood pressure discrepancy would have likely been missed and we could easily have missed her aortic dissection. Clues to the presence of the dissection only included the multiple locations or distribution of the pain – abdomen, chest, eye, “and back down” to abdomen. The only structure connecting all of those locations? The Aorta.
Chest Pain (prior case with discussion)