Aortic dissection: A challenging ED diagnosis
Ritter case shows challenges of chest pain
As we go to press, a jury has cleared two ED physicians of negligence in a $67 million lawsuit filed by John Ritter's widow Amy Yasbeck in Los Angeles Superior Court. The lawsuit stemmed from the death of actor John Ritter as the result of aortic dissection, claiming he would have survived if they had recognized his blood vessel abnormality and not treated it as a heart attack. The defendants successfully contended that it was too late for anything else to have been done that could have saved his life, and the evidence showed that Ritter had been warned about the potential danger of his condition but failed to take up follow-up treatment.
While the jury ruled in favor of the physicians, this case helps shine light on a condition that emergency medicine and cardiology experts agree is one of the most difficult to diagnose in the ED. "The challenge is the limited clinical exposure most ED physicians have to [aortic dissection]," notes Tom Syzek, MD, FACEP, director of risk management for Premier Health Care Services in Cincinnati. "You can read about it all you want and even know the super classic presentations, but there are so many variables." These two factors, he asserts, "contribute to delayed or missed diagnoses."
Aortic dissection is not always considered in a differential diagnosis, experts say. Jose J. Lopez, MD, assistant director of clinical operations in the ED at Franklin Square Hospital Center in Baltimore, says that to correctly diagnose aortic dissection, "you first need to get the thought it may be there. When you see chest pain, you are more likely to think about coronary artery disease first." To arrive at the correct diagnosis, "You have to come up with a suspicion based on clinical history and symptoms," he says.
What to look for
When someone presents with chest pain in the ED, you need to think first about the three causes of chest pain that are potentially fatal: acute myocardial infarction (AMI), pulmonary embolism, and aortic dissection, says Richard Lewis, MD, FACC, medical director of clinical cardiology services at Mary Washington Hospital in Fredericksburg, VA.
"The classic presentation for all of these are helpful, but they are not a 100% guarantee," Lewis says. The classic MI involves crushing chest pain, he says. A pulmonary embolism involves shortness of breath and painful breathing. The classic aortic dissection is not difficult to diagnose, Lewis says. "It is characterized by a tearing or ripping sensation in the chest or back, or both," he says.
However, these symptoms can overlap, and the patient also might have atypical symptoms such as syncope, sweating and weakness, nausea, or even significant heartburn or indigestion, Lewis says. "You have to be pretty quick with all three of these potentially fatal conditions, because time is of the essence," he emphasizes.
Syzek agrees. "Aortic dissection probably has the highest mortality rate of these conditions with mimicking symptoms," he says. Syzek notes that mortality increases 1%-2% for every hour of delay in the first 24-48 hours.
Even very young patients can suffer aortic dissection, due to conditions such as Marfan syndrome, which is a genetic disorder of the connective tissue. Those with Marfan have a predisposition to cardiovascular abnormalities, specifically those affecting the heart valves and the aorta. Because of this predisposition, "you have to treat chest pain in virtually any age group now in the triage area as a seconds-to-minutes emergency," Syzek says. "You have to document presence or absence of chest pain and risk factors, i.e., a history of high blood pressure — even in triage. And if the answer is yes, your thought process should shift to aortic dissection."
That shift should occur even if the triage EKG is normal, Syzek says. "I would say, especially if it is normal," he emphasizes. When a patient who presents with the chief complaint of non-traumatic chest pain (not all dissections do) and has a normal EKG, "that is a good time to include dissection in the differential diagnosis," Syzek says. Ask yourself this question, he suggests: If a patient continues to have chest pain and there is no EKG (or cardiac enzyme) evidence of acute coronary syndrome, do you stop there? "Of course not!" he replies. "Other life-threatening causes for the chest pain have to be at least considered, including mainly PE and dissection."
Lopez says, "I usually start by asking nurses to check blood pressure in both arms or to take a plain X-ray of the chest, unless the suspicion is high enough to order them straight to a CT scan." A key allegation in the Ritter case is that a chest X-ray never was performed in the emergency department.
Failure to order appropriate studies, such as a CT scan, MRI, or EKG, can lead to inadvertent treatment of other conditions that mimic aortic dissection, notes Syzek. If you suspect a heart attack and give thrombolytics to a patient who has an aortic dissection, "then you can have a disaster," he says.
Educate your staff
For ED managers, Syzek recommends an "educational endeavor" in which you teach triage and early intake personnel.
"Emphasize that chest pain is a seconds-to-minutes condition, that the age of aortic dissection patients can vary greatly, and that they must be sure to document risk factors," he advises. "Consider dissection when pain persists, despite the absence of coronary ischemia."
Lopez agrees. "I would absolutely do inservices," he recommends. "We often review these cases when they come up."
Another strategy to consider is using diagnostic software developed for personal digital assistants (PDAs). One free program Lewis is aware of is called Diagnosaurus, from New York City-based McGraw-Hill. "You punch in a symptom and it will give you the differential, which is a good aid to have," he says. "You won't make the diagnosis if you don't think about it."
Resources
For more information on the Diagnosaurus software, and to download a copy free of charge, go to: www.diagnosaurus.com.
As we go to press, a jury has cleared two ED physicians of negligence in a $67 million lawsuit filed by John Ritter's widow Amy Yasbeck in Los Angeles Superior Court.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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