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Difficulty: MediumCardiothoracic and Vascular Surgery

A 7171-year-old man is transported to the resuscitation bay after collapsing at his home. His daughter, who witnessed the event, reports that he suddenly complained of an agonizing, tearing pain in the center of his chest that radiated to his upper back right before losing consciousness. His past medical history is significant for poorly controlled hypertension, chronic obstructive pulmonary disease, and a prior exploratory laparotomy for a small bowel obstruction.

On physical examination, the patient is lethargic, diaphoretic, and pale. Vital signs are:
Temperature: 36.9∘C36.9^\circ\text{C} (98.4∘F98.4^\circ\text{F})
Heart rate: 128 /min128\text{ /min}
Blood pressure: 76/42 mm Hg76/42\text{ mm Hg}
Respiratory rate: 26 /min26\text{ /min}
Oxygen saturation: 92%92\% on room air.

Cardiovascular examination reveals distended neck veins, faint heart sounds, and a newly appreciated high-pitched, blowing early diastolic murmur best heard at the right upper sternal border. Lung auscultation is clear bilaterally. The abdomen is soft and non-distended.

A bedside point-of-care ultrasound demonstrates a large pericardial effusion with right ventricular diastolic collapse, as well as a visible intimal flap in the proximal ascending aorta.

Based on the clinical and sonographic findings, what is the best initial intervention for this patient?

  1. A
    Computed tomography angiography of the chest, abdomen, and pelvis
  2. B
    Intravenous administration of furosemide and nitroglycerin
  3. Immediate operative repair of the ascending aortaAnswer
  4. D
    Initiation of bowel rest and serial abdominal examinations
  5. E
    Withhold intervention until a healthcare proxy can provide formal consent

Answer

Immediate operative repair of the ascending aorta
The correct answer is immediate operative repair of the ascending aorta. This patient presents with classic signs of a Stanford Type A (ascending) aortic dissection, including sudden tearing chest pain radiating to the back and a new high-pitched early diastolic murmur (indicating acute aortic regurgitation). The bedside ultrasound confirms the diagnosis by visualizing the intimal flap and also reveals a large pericardial effusion with right-sided heart collapse, indicative of cardiac tamponade. A Type A dissection is a surgical emergency. Because this patient is hemodynamically unstable (hypotensive, lethargic) and the diagnosis has been confirmed on bedside imaging, the patient must be transferred immediately to the operating room for a median sternotomy and repair.

Step-by-Step Solution

1
Analyze the clinical presentation and physical examination findings.
The patient presents with sudden tearing chest pain, hypotension, distended neck veins, a new diastolic murmur, and bedside ultrasound confirming a pericardial effusion with an intimal flap.
To establish the primary diagnosis of a Stanford Type A aortic dissection complicated by cardiac tamponade and acute aortic regurgitation.
2
Assess the patient's hemodynamic status.
The patient is in obstructive and cardiogenic shock, evidenced by lethargy and a blood pressure of 76/42 mm Hg76/42\text{ mm Hg}.
Hemodynamic stability dictates whether a patient can safely undergo further diagnostic imaging or requires emergent intervention.
3
Determine the most appropriate next step in management.
Immediate surgical intervention (median sternotomy and repair) is selected.
In a hemodynamically unstable patient with a bedside-confirmed Type A dissection, emergent surgery is the only definitive life-saving therapy.

Key Concept

Hemodynamically unstable patients with a highly suspected or bedside-confirmed Stanford Type A aortic dissection require immediate surgical repair, bypassing confirmatory advanced imaging such as CT angiography.
Estimated Time:1m 30s
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Topics

Cardiothoracic and Vascular Surgery

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