Ultrasound Case #1 – The Chest Pain Transfer
A 56 year old male with a history of hypertension is transferred to your hospital from an outside facility. The outside facility transferred the patient because the did not have cardiology services and the patient was thought to be having an NSTEMI due to elevated troponins and chest pain. On arrival to your facility the patient says that he has severe anterior tearing like chest pain that started suddenly a few hours ago. He also notes that he has severe numbness of his left arm. He denies any history of smoking and says that he is very active exercising almost daily and never has any chest pain or shortness of breath.
Vitals on arrival: HR 120, BP 190/110, RR 24, Sat 98% on RA
The patient appears very uncomfortable and looks ill. You place an ultrasound on his chest and see the following images:
What do you see happening in these clips? What are your next steps in management?
Click to reveal answer
Clip 1 is a parasternal long axis view of the heart showing a dilated aortic root with a dissection flap visible in the ascending aorta. There is no visible pericardial effusion and the ejection fraction appears normal.
Clip 2 shows a normal parasternal short view without pericardial effusion.
Clip 3 is a suprasternal view of the aortic arch. You can see a dissection flap midway though the clip on the right side of the image.
Management: The patients blood pressure and heart rate need to be controlled and vascular surgery needs to be notified immediately. Remember that you should start with heart rate control using a beta-blocker first to avoid reflex tachycardia when you lower the blood pressure. A general rule of thumb is to control the heart rate and give the patient something for pain, this is occasionally enough to lower the blood pressure without additional medications.
Click to reveal learning points
- Ultrasound GEL podcast did a great episode on this topic that can be found here
- When direct signs of a dissection flap are visible on TTE +LR for dissection is 17.4.
- Aortic root dilation >4 cm was seen in 70% of cases in the Nazerian study, personally I advocate for checking the size of the aortic root in every chest pain patient.
- More information on the suprasternal notch view can be found here
- EMCrit covered mangement pearls of aortic dissection back in 2013 and that can be found here
REFERENCES
1. Nazerian P, Vanni S, Castelli M, Morello F, Tozzetti C, Zagli G, et al. Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection. Intern Emerg Med. 2014;9(6):665–70.