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Difficulty: HardInitial Stabilization and Triage

A 62-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his back, between the shoulder blades. The pain began 3030 minutes ago while he was resting. He has a medical history of poorly controlled hypertension, hyperlipidemia, and a 4040-pack-year smoking history. On presentation, he appears in acute distress, anxious, and diaphoretic. Vital signs are temperature 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure 215/115215/115 mm Hg in the right arm and 205/110205/110 mm Hg in the left arm, heart rate 118118/min, and respiratory rate 2222/min. Oxygen saturation is 97%97\% on room air. Cardiovascular examination reveals a regular tachycardia and a new, faint decrescendo diastolic murmur heard best at the right upper sternal border. The lungs are clear to auscultation bilaterally. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no acute ischemic changes. Which of the following is the most appropriate immediate next step in management?

  1. A
    Obtain computed tomography angiography of the chest
  2. B
    Administer intravenous sodium nitroprusside
  3. Administer intravenous esmololAnswer
  4. D
    Obtain a bedside transesophageal echocardiogram
  5. E
    Administer oral aspirin, sublingual nitroglycerin, and consult interventional cardiology

Answer

Administer intravenous esmolol
The clinical presentation of sudden-onset, severe, tearing chest pain radiating to the back in a highly hypertensive patient is classic for an acute aortic dissection. The new decrescendo diastolic murmur indicates aortic regurgitation, suggesting proximal extension of the dissection flap (Type A). The immediate priority in patient management (initial stabilization) is 'anti-impulse' therapy to rapidly lower the heart rate (target ≤60\leq 60/min) and systolic blood pressure (target 100−120100-120 mm Hg). This reduces the left ventricular ejection force and aortic wall shear stress (dP/dtdP/dt), minimizing the risk of dissection propagation and rupture. Intravenous beta-blockers (e.g., esmolol, labetalol, or propranolol) are the drugs of choice and must be administered as the absolute first step in management, even before definitive diagnostic imaging is obtained.

Step-by-Step Solution

1
Analyze the clinical presentation and physical exam findings.
The patient's sudden-onset tearing back pain, severe hypertension, and new murmur of aortic regurgitation strongly suggest an acute aortic dissection.
Establishing a high-confidence working diagnosis directs the immediate triage and stabilization pathway, separating it from acute coronary syndrome protocols.
2
Determine the most critical stabilization priority.
The immediate goal is to rapidly reduce aortic wall shear stress (dP/dt) to prevent dissection propagation and catastrophic rupture.
Hemodynamic instability and continued high mechanical stress on the aortic wall are the primary causes of early mortality in acute aortic dissection.
3
Select the appropriate initial pharmacologic intervention.
Intravenous beta-blockers (such as esmolol or labetalol) are the first-line agents to lower heart rate to ≤60\leq 60/min and systolic blood pressure to 100−120100-120 mm Hg.
Beta-blockers must be administered as the absolute first step in management, before definitive imaging and before any vasodilators are given.

Key Concept

In suspected acute aortic dissection, immediate initial stabilization requires anti-impulse therapy with intravenous beta-blockers to reduce heart rate and blood pressure before definitive diagnostic imaging or administration of vasodilators.
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Topics

Initial Stabilization and Triage

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