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JCM 4 th June 2014. History M/28 Chinese Police Cadet History of back pain treated conservatively 2011 Severe upper back pain after firing a pistol in.

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Presentation on theme: "JCM 4 th June 2014. History M/28 Chinese Police Cadet History of back pain treated conservatively 2011 Severe upper back pain after firing a pistol in."— Presentation transcript:

1 JCM 4 th June 2014

2 History M/28 Chinese Police Cadet History of back pain treated conservatively 2011 Severe upper back pain after firing a pistol in Cadet School No SOB, no weakness, no radiation

3 Examination Triage Cat 4 BP 124/66 mmHg, P63/min Temp 35.7C, SpO2 100% Mild tenderness at the paraspinal area of T- spine Chest clear Abdomen soft and no tenderness


5 Our management CXR: no pneumothorax, pneumomediastinum Ketorolac IMI given Pain decreased after IMI Advised to avoid physical exercise Discharged with NSAIDs and sick leave for 1 day

6 4 days later Noticed right leg pain and numbness Feeling coldness of right leg Patient worried about side effects related to the previous IM Ketorolac Circulation normal No neurological deficit Lower limb power full

7 X-ray T-L spine

8 DDx? Sprain back? PID with radiculopathy? Right leg DVT? Other possibilities? ……

9 Outcome Admitted to Ortho QMH in view of pain Suspected T9 collapse at lateral X-ray by Ortho Private MRI spine referred Noticed type B aortic dissection on MRI Both leg warm and abdomen soft Vascular team consulted and agreed to takeover

10 CT Aortogram



13 Type B aortic dissection from distal aortic arch down to right iliacs/ CFA No coronary artery stenosis Both kidneys perfused symmetrically False lumen compressing true lumen leading to decreased blood flow to both lower limbs

14 Management BP controlled with beta-blockers Pain well controlled Discharged home D13 after admission


16 2 months later, endovascular stenting was done in QMH in view of young age and involvement of the right iliacs/ CFA

17 Long term management Follow up with contrast CT in 6 months BP control with home BP monitoring Advised light duty and to avoid competitive sports/ collision

18 Acute aortic dissection (AAD) A potentially catastrophic disease that remains difficult to diagnose in the emergency department Circulation 2010 – Mortality 40% for immediate death – 1% per hour for incremental death thereafter – 20% for perioperative death – 50% to 70% reported survival rate after initial surgery

19 Epidemiology True incidence is unknown Population-based prevalence studies have estimated the incidence to be about 3 cases per 100000 people per year Higher incidence in men (65%) and with increasing age

20 Significant medicolegal issues surrounding missed diagnosis of AAD Common misdiagnoses – Acute coronary syndrome (19%) – Musculoskeletal pain (20%) – Pneumonia/ pulmonary embolism (20%) – Pericarditis (12%) – Gastrointestinal pain (9%) – Other causes (20%)

21 Consider the diagnosis of AAD in situations of – Sudden severe chest pain – Accompanying visceral symptoms (nausea, vomiting, pallor, diaphoretic) – Normal/ minimally abnormal ECG findings – Inappropriate reliance on classic features

22 Classification

23 Clinical assessment in the ED Risk factors Presentations Physical findings End-organ presentations

24 Risk factors

25 Presentations Sudden-onset severe chest pain (91%) Visceral symptoms – pallor, vomiting, diaphoresis (78%) Intermittent pain (75%) Radiation to back/ neck/ arms/ jaw (69%) Pleuritic/ positional pain (44%) Pyrexia (22%) Syncope (9%) Tearing quality (3%)… CMPA case review series of missed AAD (n = 32 patients)

26 Poor reliance on the presence or absence of these features High level of suspicion is needed

27 Physical findings Peripheral pulses in the upper extremities/ blood pressure differentials New aortic regurgitation murmurs Complications of acute aortic regurgitations – Congestive heart failure, cardiogenic shock, pericardial tamponade, Mass compression effects on adjacent structures – SVC, sympathetic chain, recurrent laryngeal nerve, tracheobronchial tree, esophagus…

28 Unreliable and frequently absent in patients with AAD

29 End-organ presentations Cardiovascular: AR and related disorders, pulse deficits, BP differentials, syncope, MI, CHF, cardiogenic shock, conduction abnormalities… Syncope: cardiovascular, neurologic Neurologic: intracranial, brainstem, spinal cord, lower extremities Ears/ nose/ throat: mass effects on trachea, esophagus, RLN, sympathetic chain Respiratory: mass effects on tracheobronchial tree, hemorrhage into lung tissue/ pleural space, pleural effusions GI: mesenteric ischemia, aortoenteric fistula

30 Diagnostic tests ECG (non-specific change) Laboratory markers (currently no sensitive/ specific test) – Soluble elastin fragments, smooth muscle myosin heavy chain, WBC, hsCRP, fibrinogen, D-dimer

31 Diagnostic images Chest X-ray – Abnormal aortic contour, mediastinal widening, pleural effusion, displacement of intimal calcifications, abnormal aortic knob, displacement of trachea or NG tube deviation to the right…

32 1.Mediastinal widening 2.Widening of aortic contour

33 Calcium sign

34 Diagnostic images (continued) CT Transesophageal echocardiography MRI

35 Circulation 2010

36 Management of type B AD Mainly Medical treatment in form of BP control – Maintain PR <60/min by Beta blockers and SBP <120mmHg [Class I; level C] – 1 month survival 89% – 1 year survival 84% – But poor long term outcome: Mortality 30-50% at 5 year Surgical Intervention – Indicated in complicated AD: malperfusion, rupture, rapid expansion esp false lumen, extension, severe pain, failed to control BP [Class I; level B] – Open Surgery: High mortality in the past – Endovascular Stenting: Maybe more superior but lacking evidence on long term survival Circulation 2010

37 Endovascular Interventions (TEVAR)

38 Follow up Close follow-up visits Long-term medical therapy with beta-blockers Serial imaging – 1, 3, 6 and 12 months post-dissection – Annually thereafter if stable

39 Summary for AAD Rare but potentially catastrophic Presentation and initial assessment findings are always non-specific High index of suspicion is needed CT is the most common diagnostic modality initially used Initial management with BP, heart rate and pain control important Subsequent definitive surgical consultation

40 Failure to consider AAD in these situations (and document risk assessments accordingly) can lead to clinically adverse outcomes for patients and medicolegal liability for physicians

41 References Upadhye S, Schiff K. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management. Emerg Med Clin North Am. 2012 May;30(2):307-27, viii. De Leon Ayala IA, Chen YF. Acute aortic dissection: an update. Kaohsiung J Med Sci. 2012 Jun;28(6):299-305. Hiratazka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation 2010;121:e266-369.

42 References (continued) items/aortic-dissection-cxr-findings/ m+Sign

43 Thank you

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