Takeaway: Aortic dissection may progress slowly. The sooner it is diagnosed, the better. New onset chest pain requiring morphine should be a red flag.

Diagnostic Aids

Prediction Scores: The Aortic Dissection Detection Risk Score (ADD-RS) can reduce the chance of missing the diagnosis.³ It emphasizes three areas of focus:

1. High-risk conditions (family history, aortic valve disease, Marfan’s, etc.)
2. High-risk pain features (sudden onset, severity, quality)
3. High-risk examination findings (pulse deficit, murmur, neurological deficit, etc.)

POCUS: Point-of-care ultrasound for AD is highly specific, but operator-dependent, and lacking in sensitivity—although late–model units can have sensitivity as high as 80-85 percent.⁴ It can be quick, if positive, and reduce time to surgery while awaiting a confirmatory CT angiography. Views of the carotids and the abdominal aorta if stroke symptoms or abdominal pain is present is an added benefit.

Dr. Dajer was emergency department medical director at NY Presbyterian Lower Manhattan Hospital for 13 years.

Dr. Pilcher is a retired emergency physician and ED medical director at EvergreenHealth in Kirkland, WA. He has served as a medical-legal consultant in malpractice cases throughout his career and is the editor/publisher of a free opt-in monthly newsletter “Medical Malpractice Insights – Learning from Lawsuits.”

References

1. Hansen MS, et al. Frequency of and inappropriate treatment of misdiagnosis of acute aortic Dissection. Am J of Cardiology. 2007;99(6):852-856.
2. Von Kodolitsch Y, et al, Clinical predictors of acute aortic dissection. Arch of Int Med. 2000;160(19):2977-2982.
3. Rogers AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of AAD at initial presentation. Circulation. 2011;123:2213-18.
4. Cecconi M, et al. The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome. Am Heart J. 2012;163(1):112-18.