In a morning ED handover on a chilly winter day, your collea | Figure 1
Case Summary
In a morning ED handover on a chilly winter day, your colleagues from the night shift present the case of a female patient in her late 40s. She was brought to you after what appeared to be a new-onset partial seizure. She is not pregnant, has no infective symptoms and all her vital signs are normal. She has no past medical history of significance and does not take any regular medicines. She has no chest pain or breathing difficulty. After a normal reassuring brain CT and an unremarkable blood panel and blood gas, the patient is discharged with follow-up in the first-seizure neurology clinic. There is nothing suspicious about the case and you are in agreement with the night team about the plan. The patient is discharged. You get on with the rest of your day.
About an hour before the end of your shift, you’re notified of a new priority patient en route to your ED.. probably your last patient of the day. Ten minutes later, as you’re taking the handover from the ambulance crew in your resus, you feel a chill down your spine! It’s the same patient from this morning. The one for the first-fit clinic? She’s come back with lightheadedness, her blood pressure is 70/40, yet she has no chest pain or breathing difficulty, no headache, no neck pain. She has a clear chest and her abdomen is soft. Her face is flushed and her peripheries feel cold and clammy. She has weak but regular radial pulses, but her distal leg pulses are not palpable. Her lactate on the blood gas is 8, PH:7.2, bicarb is 7, ketones are elevated and blood sugar is 390 mg/dl. Remember the patient was not known to be diabetic, yet with those numbers, you start treatment for suspected DKA and possible sepsis. Your critical care team is in agreement. But the patient is deteriorating fast and you need answers quickly. You organise a CT scan of chest, abdomen and pelvis. But the patient will probably not make it safely to radiology and back. You settle for a portable chest film. What you’re about to see is going to surprise you.
The mediastinum is unequivocally widened, like you’ve never seen before in a patient this age. Acute aortic dissection is later confirmed. The patient is sent for intervention but the prognosis is not good.
Painless aortic dissection is actually a well recognised entity. A number of studies on similar presentations of aortic dissection are forcing us to rewrite the "classic" description of how AAD presents to the emergency department (https://www.medscape.com/viewarticle/885676).