04 February 2009

A jolt of adrenaline

I had a weird shift, with a strange predominance of chest pain patients.   Nothing unusual about that per se, but they were strange chest pain patients.  The median age was 28, and all of them had very atypical symptoms -- sharp pain, pleuritic pain, burning pain, pain associated with itching, pain associated with half the body going numb, pain associated with a sudden urge to go shopping, you get the drift.

So, what can you do?  I did the drill and worked them all up appropriately.  Every once in a while I would shake my head at the 28-year-old who had a (negative) troponin on the chart. (But doctor, the protocols say everybody above 25 gets a troponin and coags and...)   So I thanked the nurses for following the protocols and sent all the chest painers home, except for a couple who had enough risk factors to buy themselves a rule-out.

One of the last chest painers I saw was a middle-aged guy, totally healthy, with atypical pain and a lot of anxiety.   His pain was sternal, and worse when I touched it, and he was hyperventilating.   I probably was going to admit him for a rule-out based on age alone, but I had no expectation that he would have real pathology as the cause for his pain.   Just one more pointless expenditure of time and money to reassure the perfectly healthy.  So he got the full battery of tests and some morphine (which did nothing) and some ativan (thank you very much, doctor, I feel better now).

I pride myself on reading all my own x-rays and ct scans, even though we have excellent local teleradiologists.  I enjoy it, it's a bit faster in most cases than waiting for the read, and it's good practice.   So as I was getting the admitting packet together, I took a look at the patient's chest x-ray.

tortuous
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The radiologist had commented on a tortuous aorta, but to me it just didn't look right.   My (overactive?) imagination thought the whole aorta looked plump.   The red arrows make it look more obvious, since the right heart border and the aortic margin are sort of superimposed.  It wasn't a particularly striking CXR without the "hey dummy" arrows in place.  I asked the rad what he thought, and got the standard "well, could be, but it's hard to say, if you are concerned, get a CT."   I double checked the blood pressures -- symmetric, and re-interviewed the patient to verify that the pain was not tearing or radiating to his back.  Well, I thought, why not?  I've chased wild geese for less in the past, so I ordered the CT.  The study was done gratifyingly quickly for so late in the shift, and I lazily scrolled through the images before the patient was even back in the department.  this is what I saw:
dissection arch
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At the level of the aortic arch.

dissection
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A bit below that level.

This is where I got my jolt of adrenaline.   No way was I expecting this to be the real deal.   It went all the way down to the iliac arteries.  For the non-medical types reading, this is an Aortic Dissection, in which a small tear in the lining of the aorta allows the blood to separate the layers of the aorta and create a "false lumen" or a separate compartment within the aorta.   The shearing forces of the pulse cause the separation to propagate on down the aorta.   This can cause all sorts of complications, from clotting off important arteries (coronary, carotid, renal, vertebral) to simply rupturing and causing death (which is what killed John Ritter).   The red arrows on the CT scan show (so clearly and beautifully) the initimal flap and false lumen, and the aorta in the lower image is quite distended indeed -- probably not far from the rupture point.

The classic presentation in this case was simply absent -- the characteristic pain and physical findings were not present.  The CXR is notoriously non-specific: in most cases of dissections, the CXR is abnormal, but rarely in a specific way to point a practicioner toward a dissection.   It was pure luck that I had taken a look at the x-ray myself and given it some thought.   I wiped my brow as the cardiothoracic surgeon and her team wheeled the patient off to the OR, as this would have been an easy diagnosis to miss (at least initially) and the consequences would have been lethal.

The only take-home point that I can think of here (other than to read your own films and be suspicious) is that I have now diagnosed about a half-dozen dissections in my career, and the one thing they have all had in common is that they were all very anxious.  Some were pretty classic, some were not, but all of them had that "something's not right" fear written on their faces.   It's a pity that anxiety is sensitive but not specific for dissection, as all of my chest painers were anxious that night.

Another bullet dodged.   I love this job.

17 comments:

  1. ~claps~ I LOVE all the films. I never knew exactly what a dissecting aorta looked like before! (not that i NEED to know as a nursing student, but i LIKE to know)

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  2. A few decades ago, a minor public official in my city died of what was described as a heart attack. He was scheduled to make some sort of routine presentation to a city board, and, while waiting, became very anxious. No one understood why since it was fairly routine matter.

    It must be difficult in the OR to distinguish between anxiety caused by chest pain, and chest pain caused by anxiety.

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  3. Was always taught "sense of impending doom", compared to anxiety etc, is a symptom that should be taken seriously in any patient.

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  4. Very nice! How did his surgery go?

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  5. Wow! I bet the the ct tech was bitching then all the sudden "holy crap get him out of my department NOW" LOL

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  6. Wow thanks for sharing, that's a crazy case. We just learned about aortic dissections in 1st yr anatomy yesterday, and your CT is better looking than the examples we had in class. Have you ever dx'd any that didn't head on up to the OR?

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  7. Hi, I was just wondering, what are the "classic symptoms" of an aortic dissection? I have Ehlers-Danlos III (hypermobily), and am therefore at a much higher risk than most to die from one, and I'm just wondering what I should be watching for.

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  8. I got a jolt myself looking at that.

    Classic aortic dissection: "tearing" or "burning" type pain, radiating to the back.

    Physical findings: asymmetric blood pressures +/- signs of ischemia to various organs.

    Bad stuff. Keep your bp under control (no salt for you), buy a monitor, and try not to worry about it.

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  9. I got a little chill reading this. Trying to figure out what specialty to pursue. I am between IM and EM. Posts like this make me think EM is where it's at :) But wasteful, CYA medicine makes me lean towards IM...though it seems more and more defensive medicine is happening there too, I still think of EM as the pinnacle of defensive medicine. And rightly so. It's unavoidable to some extent. Also, everyone lectures me about "physician burnout" and EM docs having early retirements or switching to other specialties because they burn out at age 45.

    Sigh. I have a few months to decide...I'm going to dig in your archives to see if you're done any why-I-love-EM posts, but I would love to hear why you picked EM and if you could go back, if you'd pick it again...

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  10. Nice work SF. Though I can remember diagnosing a carotid dissection (ER doc tried to do an IJ and cannulated the carotid instead) on a 17 year old kid. It looked classic on u/s, you could see the false lumen and turbulent blood flow etc, etc.

    They took him to CT and the rad confirmed it so off to the OR he went to see our top vascular surgeon. The surgeon called me down to the OR a bit later and had me step over to the surgical field to show me that the "flap" was actually just a thrombus (the kid had been opened up from the aortic arch to the neck). Needless to say I felt like crap and probably would have committed harakiri had it not fooled the rad/CT too.

    Hope things turned out well for your patient.

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  11. Outcome: 8 hour surgery with replacement of entire aortic arch. Discharged post-op day 4 (!!) with no complications.

    Hooray!

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  12. Red Rabbit
    I've been told to consume more salt, bcause my blood pressure is so low, I'm at risk of passing out every time I stand up.

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  13. holy shit close call dude.

    couple nights ago i saw a lady with pleuritic cp and no gi complaints, decided to order a pe-protocol chest ct and when checking the creatinine i noticed that the nurse added on lfts for god knows what reason. well guess what they were wicked high. so i changed the chest ct to an abdominal ct (late night, u/s not available)- gallstones, thickened gbw, pericholecystic fluid.

    a comple months ago i saw a guy with ruq pain, temp 100.3, vomiting, positive murphy sign. again ct ordered since it was off-hours. wbc11, lfts normal. the surgeon i called gave admit orders and asked me to call if the ct showed anything "funny." well the ct showed a normal gallbladder and a pe in the base of the right lung.

    so this job will certainly keep you on your toes!

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  14. Liz: see this previous Dr. SF post:

    http://allbleedingstops.blogspot.com/2005/12/boy-did-i-make-right-choice.html

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  15. I am so creeped out. I have an aortic aneurysm, with increasing aortic insufficiency (from a bicuspid valve) and have flirted with CHF for the past 20 years. The thing was found just before some surgery in August and the only guidance I got was over the phone later that day with the cardiologist who laughed when I asked him what symptoms to look out for. When he stopped giggling, he said "Don't worry, you won't have time to notice." I have been dealing with a different problem ever since, but the thought of this thing dissecting or blowing is never far away. There has got to be something I can look to as a warning.

    Oh. Yeah. And my BP is now high, after a lifetime of being way low -- averaging 80/50 most of my life. But in the past 6 months? Almost always it is 160/110 -- but it is being taken via a wrist cuff -- can that throw the readings off?

    Okay, I am leaving now. Maybe some booze...

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