High risk for BADNESS
Case 11 | Self employed middle aged male who never goes to a Dr?…….they’ve got something BAD going on….you just have to find it!
A 58-year-old truck driver from out of town checked into a hotel after a long day of driving. While resting in bed, he was suddenly seized by a sharp jaw pain that felt like a “shock” and which soon spread to the anterior chest. He had never had a similar pain before. It did not abate and he reported to the emergency room at a nearby hospital. At the hospital he was still in acute distress with chest pain. He was taking medicine for hypertension but otherwise his medical history was unremarkable. His pulse was 90 beats/min and his blood pressure was 150/90 mm Hg; otherwise the physical examination, chest x-ray, and blood tests, including troponin, were unremarkable. The ECG tracing did not show any findings of acute coronary syndrome (ACS)
What should be the next step of management?
1. Considering that the patient is stable, pain is improving (not as severe as at the onset), normal chest x-ray, and negative troponins, schedule a stress test the following morning
2. CT angiogram of the chest (or cardiac MR or transesophageal echocardiogram [TEE]) immediately looking for an acute aortic dissection
Answer
1. CT angiogram of the chest (or cardiac MR or TEE) immediately looking for an acute aortic dissection
Discussion
The team taking care of the patient did not take any further steps.
They felt reassured by the patient being “stable” with improving chest pain (pain less severe than at the onset), by the ECG not showing any findings of ACS, by negative troponins, and by the chest x-ray not showing widened mediastinum.
They scheduled a stress test for the following morning.
The patient coded 8 hours later and could not be resuscitated.
The autopsy showed an acute proximal aortic dissection with rupture.
Truck drivers are usually tough people who would not seek medical attention for a minor complaint, especially in the middle of hauling a load from one town to another.
This patient is saying, without being explicit, “Doc, believe me. Something big happened in my chest. Please find it.”
So the team caring for this patient should not have left the patient alone until this “big thing” was found.
The ECG ruling out ACS should have made the team exclaim, “We may be dealing with an acute aortic dissection!” rather than feeling reassured.
In proximal aortic dissection, if the outer layer of the dissected aorta bulges out, the mediastinum will be widened, but if the inner layer buckles in without the outer layer bulging out, the mediastinum will not be widened (see the drawing above).
The chest pain in proximal aortic dissection is cataclysmic at the onset, while in ACS it behaves in crescendo.
So, the pain becoming less severe than at the onset does not mean that the condition is “improving”; it is the natural course of the pain in aortic dissection.
Sometimes, an unremarkable ECG should be more frightening.
