1. Emergency Ultrasound in Chest pain: Acute Aortic Syndrome
Stephen Gletsu MD CCFP(EM) Department of Emergency Medicine King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia

2. Case 1
47 year old female CC- Chest Pain - retrosternal , radiates to mid back and epigastrium -severe , sudden onset 20 minutes prior to ED presentation PMhx- hypertension Rx- losartan - SLE atenolol - chronic renal failure amlodipine

3. Case 1
Physical examination vital signs - RR 18 , Sao2 100 % RA , HR 80 BP 200/95 general – alert , oriented , uncomfortable in severe pain head and neck- normal chest – AE equal , no abnormal sounds cv – no BP differential , equal pulse - normal heart sounds , no murmur abd- soft, non tender , no masses neuro- normal

6. Case 1
Is there an indication for ED US in this pt ?

7. Objectives
1)Define the Acute Aortic Syndrome (AAS) 2) evidence supporting ED US in AAS 3)technical aspects of image acquisition and review normal / abnormal images 4) limitations of ED US/AAS 5) clinical utility and suggested role for ED US in Diagnostic pathway of AAS

8. Acute Aortic Syndrome (AAS)

9. Classification of AD

10. Complications of AD 1)Pericardium Effusion Tamponade
2)Aortic valve Acute Regurg Card Shock
3)Coronary arteries ostial occlusion AMI
4)Carotid arteries occlusion Acute Stroke
5) Aortic branch arteries occlusion limb
ischemia, paraplegia, renal/bowel ischemia
6)media/adventitia rupture Hypovol Shock

11. Epidemiology of AD
IRAD - Relevant findings for EP 1) high mortality (1- 2%/ hour in first 48hrs ) 2)clinical presentation diverse-serious complications occur rapidly 3) classic physical findings infrequent (murmur,pulse deficit, BP differential) 4) ECG/CXR unhelpful

12. Epidemiology of AD IRAD - Relevant findings for EP (IRAD)
5) Type A Dissection
- 2/3 of all cases type A
- overall mortality - 35 % (type B 14%)
- at presentation:
-25% hypotensive
-13% shock

13. Current Diagnostic Standard
TEE/ CT / MRI -highly sensitive and specific “Why Bother with ED Ultrasound?” Definitive - not immediately available Testing -requires moving patient (CT,MRI) -requires intravenous contrast(CT,MRI) - requires sedation (TEE)

14. The Role of ED Ultrasound in AD
1)Rapidly establish diagnosis 2) Decrease time to medical Tx 3) Decrease time to definitive testing 4)Decrease time to surgical consultation/operative intervention

15. Evidence for ED U/S AD -Emergency Medicine literature is minimal
- mostly EM case reports ( 15 cases from 6 authors , to present)
1)Perkins et al, Journal of Emergency Medicine, Nov 2008
2)Budhram et al, Academic Emergency Medicine, Dec 2008
3)Fojtik et al, Journal Emergency Medicine, Vol 32(2), Feb 2007
4)Blaivis et al,Journal Emergency Medicine, Vol 20(4),July 2002

16. Evidence for ED U/S AD One EM study- abstract
- Sierzenski et al, Academic Emergency Medicine
Vol 11(5), pp , 2004
- retrospective study- all pt w/AD over 21 months
- compared those who had ED performed
US to identify widened Aortic root(>3.8 cm) or
intimal flap to those who did not and found
statistically significant decrease in time to
CT, B-blocker and OR

17. Evidence for ED U/S AD - Cardiology literature
- most of studies on TTE in AD
- introduction of TEE
- Roudaut et al, Clinical Cardiology,11, ,
1988
- prospective study of transthoracic ,
suprasternal and transabdominal US
in AD
- 628 pt w/ suspected AD -> 128 pt
confirmed AD(angio,CT,surgical,autopsy)

18. Evidence for ED U/S AD 1) Aortic Dilatation (sens 95%,spec 51%)
Roudaut et al, Clinical Cardiology,11, , 1988
- 2 echo features support dx of AD
1) Aortic Dilatation (sens 95%,spec 51%)
a) Ascending Aorta- >4 cm
b) Aortic arch- >3.5 cm
c) Abdominal Aorta >3 ccm
2) Abnormal linear intraluminal image
suggesting intimal flap(sens 67%,spec 100%)
a) long ( 1 cm) - i)highly mobile, oscillating,
sail- like motion
ii)minimally mobile ( most frequent)
parallel to aortic wall

19. Case 1-Parasternal Long Axis

20. Case 1- Suprasternal

21. Case 1-Abdominal aorta

22. ED US/AAS Probe positions
1)PSLA(+/- other cardiac views) a)Aortic Root Diameter b) Intimal flap c)Pericardial Effusion d) Global LV function 2)Suprasternal View a)Aortic arch Diameter b)intimal flap 3)Abdominal aortic view(transverse/longitudinal) a) Abdominal Aortic diameter

25. Parasternal Long Axis view

35. Suprasternal view

36. Suprasternal view

37. Suprasternal View

40. Abdominal Aorta-transverse

41. Abdominal Aorta-longitudinal

45. Clincal Utility of EDUS AD
Rapid bedside diagnosis to expedite medical therapy, definitive imaging, surgical referral
Rapid identification of high risk features of type A dissection- a) Aortic root dilatation
b)pericardial effusion
c ) LV dysfunction
3) Cannot rule out Aortic Dissection

46. Diagnostic Algorithm in AD
clinical suspicion of AD EDUS-AD High Risk Not High Risk diagnostic? diagnostic? Yes No Yes No Surg cons Surg cons Medical tx TEE/CT/MRI Medical Tx +/- Medical tx Surg cons Bedside TEE Bedside TEE TEE/CT/MRI

47. Case 1 TEE

48. Cases
- 2 additional cases

49. Summary
-Transthoracic /Transabdominal US in AD is an old technique - Rediscovered in emergency ultrasound - Potential to improve outcomes and physician satisfaction in management of suspected AD