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ACEP Now: June 2025 (Digital)

Image 3. Stanford Type A dissection on CT. (Click to enlarge.)

Discussion

In this case, the decision to use POCUS in an otherwise well appearing patient on initial presentation identified the unexpected pericardial effusion on a subxiphoid view. The parasternal long axis demonstrated a dilated aortic root with dissection flaps in the proximal aorta, as well as a dissection flap in the descending aorta. This immediate identification of a proximal aortic dissection facilitated expedited presurgical imaging and appropriate consultation with the cardiothoracic surgical teams. The patient had optimal time to operative repair as POCUS was utilized rather than waiting for progression of symptoms prior to identifying the underlying etiology.

POCUS is a fast and safe option to diagnose acute Stanford Type A aortic dissection (AD). Compared with CT, POCUS has been found to be highly sensitive and specific. It has no adverse effects on treatment initiation time, in-hospital mortality, or mortality within three months of discharge.​¹​

POCUS allows identification of secondary complications of AD such as hemodynamically stable pericardial effusions, which can be found in approximately 33 percent of cases​ and was identified in this patient.² Other secondary findings of AD that can be identified on ultrasound include dilated aortic root and aortic regurgitation.​²​

AD is an emergent condition that typically affects older men with an estimated mortality rate of 40 percent.³ Hypertension is the greatest risk factor for AD. Women often have worse prognosis as they are more likely present atypically, complicating prompt diagnosis and treatment of this emergent condition.​²​

This patient did not report the typical “ripping” or “tearing” chest and back pain and appeared well overall. Without the prompt application of POCUS, the diagnosis may have been delayed leading to worse outcome; the mortality rate increases with delayed diagnosis.​^2,4​ On chart review, the patient has followed up with cardiothoracic surgery and vascular surgery and is doing well.

Dr. Gore is a second-year emergency medicine resident and Chief Resident of Academics at Wright State University and a Captain in the United States Air Force at Wright Patterson Air Force Base in Dayton, Ohio.   

Ms. Fisher is a third-year medical student at Wright State University Boonshoft School of Medicine, Dayton, Ohio.