Episode 92 – Aortic Dissection Live from The EM Cases Course

This is EM Cases Aortic Dissection Live from The EM Cases Course While missing aortic dissection was considered "the standard" in the late 20th century, our understanding of the clinical diagnosis has improved considerably since the landmark International Registry of Aortic Dissection (IRAD) study in 2000. Nonetheless, aortic dissection remains difficult to diagnosis with 1 in 6 being missed at the initial ED visit. Why? The diagnosis is rare with and incidence of only 2.9/100,000/year, and the presentation is often atypical mimicking other more common diagnoses such as ACS and stroke. Each hour that passes from the onset of symptoms portends a 1-2% increase in mortality so your early, timely diagnosis is key. The most important factor leading to a correct diagnosis is having a high clinical suspicion. We need to at least consider the diagnosis in all patients with chest, abdominal or back pain, syncope or stroke symptoms, yet we shouldn’t be working up every one of them, or else we’ll bankrupt the health care system with all the CT aortograms ordered. Herein lies the difficulty. With the help of David Carr and Anton Helman we’ll discuss how to pick up atypical presentations without over-imaging as well as manage them like pros by reviewing:  1. The five pain pearls 2. The concepts of CP +1 and 1+ CP 3. Physical exam pearls 4. Initial tests pearls and pitfalls 5. The importance of the correct order and aggressive use of IV medications So with these objectives in mind… Written Summary and blog post written by Anton Helman, February 2016 This podcast was recorded live at The EM Cases Course at North York General Hospital in Toronto February 2017 Cite this podcast as: Helman, A, Carr, D. Aortic Dissection Live from The EM Cases Course. Emergency Medicine Cases. February, 2017. https://emergencymedicinecases.com/aortic-dissection-em-cases-course/. Accessed [date]. For core knowledge on aortic dissection first review EM Cases Episode 28 with David Carr and Anil Chopra A) The Five Pain Pearls of Aortic Dissection Pain Pearl #1: Ask the following 3 questions for all patients with torso pain: Quality of pain (most commonly “sharp” but highest LR for “tearing”) Pain intensity at onset Radiation of pain (back and/or belly) A 1998 study that reviewed a series of aortic dissection cases showed that for the 42% of physicians who asked these 3 questions, the diagnosis was suspected in 91%. When less than 3 questions were asked dissection was suspected in only 49%. Pain Pearl #2: Think of aortic dissection as the subarachnoid hemorrhage of the torso Just as the patient who presents with headache and is suspected of suffering from a subarachnoid hemorrhage, if the patient describes truly abrupt onset of severe torso pain with maximal intensity at onset, think aortic dissection. Pain Pearl #3: Severe colicky chest pain + opioids = heightened suspicion If you find yourself treating your chest pain patient with IV opioids to control their severe colicky pain, think about the possibility of aortic dissection. Pain Pearl #4: Migrating pain has a +LR = 7.6 In addition to the old adage "pain above and below the diaphragm should heighten your suspicion for aortic dissection", severe pain that progresses and moves in the same vector as the aorta, increases the likelihood of aortic dissection. Pain Pearl #5: The pain can be intermittent as dissection of the aortic intima stops and starts The combination of severe migrating and intermittent pain should raise the suspicion for aortic dissection.