A 55-year-old woman with medical history of well-controlled hypertension and renal cell carcinoma, status post-partial nephrectomy, presented to the emergency department (ED) with sudden-onset, 10-out-of-10 chest pain and pressure. She arrived via emergency medical services and was noted to be hypotensive with several blood pressure readings in the 60s/40s mm Hg range en route.

Upon arrival, she was normotensive with blood pressure 110/54 mmHg after receiving 250 mL normal saline. The patient was received fentanyl prior to arrival, which improved her pain to a four out of 10. She denied back pain and abdominal pain but endorsed mild nausea. On physical examination, she had no gross neurological deficits. She had a normal cardiopulmonary exam.

There was no edema or discoloration of her lower extremities. She had full strength in bilateral lower extremities but endorsed mild paresthesia in her right leg and calf. It was difficult to palpate pulses in her right lower extremity. 

Diagnosis

Image 1. Subxiphoid view with yellow star identifying pericardial effusion. (Photos courtesy Ashlee T. Gore, DO. Click to enlarge.)

The patient was well appearing, but given the report of hypotension prior to arrival and history of hypertension, point-of-care ultrasound (POCUS) was used to evaluate for etiology of hypotension in the setting of severe and sudden onset chest pain. Pericardial effusion was identified on subxiphoid view without evidence of tamponade physiology (see Image 1). Parasternal long-axis view identified a dilated aortic root, which strengthened the suspicion for aortic dissection (AD).

Image 2. Parasternal long axis view of dilated aortic root as shown by the yellow circle. Red dotted line outlines dissection flaps seen within the proximal aorta. (Click to enlarge.)

Upon later image review, dissection flaps were seen in the ascending and descending aorta (see Image 2). Once the abnormal POCUS was recognized, a CT dissection protocol with aortic runoff was ordered and the cardiothoracic surgery team was consulted.

Because of the quickly identified aortic dissection, appropriate laboratory tests and medical management were initiated while preoperative CT scanning for surgical planning was obtained. In the interim, the patient experienced worsening right lower extremity pain and she no longer had a palpable pulse in the right leg. By this time the CT imaging had been completed, and the patient was taken to the operating room for repair of significant dissection that included the aortic valve and the entire aortic arch to the level of the bifurcation with a false lumen tracking to the right iliac artery (see Image 3). After a two-week hospital course, she was discharged in stable condition to a short-term rehabilitation facility.