Aortic Dissection

Patient presentation:
R.S. is a 46 year old male. Medical history included hypertension, diabetes mellitus, and obesity as well as smoking two packs of cigarettes per day. Patient presented to the emergency department by ambulance with acute severe onset of a tearing/ripping sensation in the upper back and chest pain. The patient was diaphoretic, and screaming in the stretcher. A set of vital signs was obtained. His blood pressure was 199/125, his heart rate was 149 beats per minute, respiratory rate was 30 breaths per minute, temperature was 37.7 degrees Celsius, O2 saturation was 93% on a non-rebreather mask, and his pain was 10 out of 10 on the numeric pain scale.

Physical exam showed that R.S. was tachycardic, tachypneic with labored breathing, and extremely anxious. His lung sounds had crackles, strong murmur in the aortic valve; pedal and femoral pulses were weak and thready. The ECG showed sinus tachycardia with frequent PVCs. Blood work was obtained and three large bore IVs were placed. The physician ordered a stat chest x-ray and a stat non-contrast (due to the patient’s high creatinine) CT scan of the chest and abdomen/pelvis.

Lab values:
WBC - 3.4; INR – 2; HCO3 – 25; CPK – 3000; H/H – 5.4/18; pH – 7.25; Lactate – 11; CPK-MB – 39; Platelets – 12,400; PaCO2 – 51; Ionized Ca++ – 0.90; Troponin – 45; PT/PTT – 34/55; PaO2 – 220; K+ – 5.5

Differential List:
Myocardial Infarction, Aortic Dissection

Treatment:
While waiting for the flight team to fly R.S. to an outside hospital with specialty in emergency cardiovascular surgery, the initial treatment was close blood pressure control using a nitroglycerine drip, pain control morphine at 8 mg, and an emergency blood transfusion of O-. R.S. had emergency cardiac surgery for dissection repair, and was later transferred to the Cardiac ICU after surgery for father monitoring and recovery.