This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide.
Case: December 2017
50yM no PMH, active smoker presents by ambulance with chest pain. Six hours ago he developed substernal chest pressure and nausea, no vomiting. Pain was moderate and constant, but he had a presyncopal episode 1hr prior and severe worsening of chest pain which led him to call 911. He was given ASA en route.
PMH / PSH
No medications or known PMH
BP 109/44 | HR 95 | RR 18 | T 98.5F | SpO2 92% RA → 97% 4L NC
GEN: diaphoretic, pale, grimacing, clutching his chest in pain, speaking in incomplete sentences
CV: tachycardic, regular, 3/6 systolic ejection murmur
ABD: soft, non-tender, non-distended
NEURO: no focal deficits, moves all extremities equally
CBC: 17.6 > 15.4 / 43.9 < 189
BMP: 140 / 4.4 / 107 / 23 / 21 / 1.4 < 139
LFT: 91 / 37 / 90 / 1.6 / 0.0 / 4.2 / 7.5
VBG: 7.50 / 34.3 / 26.7 Lact 2.95
What are your next steps in management of this patient?
STEMI team was activated and the patient was started on heparin and promptly taken for cardiac catheterization. He had normal coronary arteries but was noted to have severe aortic insufficiency and a dissection flap in the ascending aorta consistent with type A aortic dissection.
What additional therapies would you consider administering?
He was started on labetalol and as the patient was being consented for emergent operative repair by CT surgery, he admitted to longstanding and recent crystal meth use. Intraoperatively, an intimal tear was noted 2-3cm above the sinotubular junction with the intimal flap dissecting through the aortic valve; graft repair was performed with good outcome.
Aortic dissections have a highly variable presentation, which makes diagnosis challenging. It is much rarer than ACS, with an incidence of 5-30 cases per million people, and a high risk of mortality (classically 1-2% increase in mortality with each passing hour) (Hagan 2000). There is no information in the literature regarding the incidence of aortic dissection among cases that present as myocardial infarctions.