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Zorluk: ZorCardiovascular System

A 65-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain radiating to his interscapular region that began 11 hour ago. He also reports progressive, severe shortness of breath over the past 3030 minutes. His medical history is significant for hypertension, hyperlipidemia, and a 4040-pack-year smoking history.

Vital signs are:
Blood pressure: 84/4084/40 mmHg in the right arm and 62/3562/35 mmHg in the left arm
Heart rate: 128128/min
Respiratory rate: 2828/min
SpO2: 85%85\% on room air

Physical examination reveals a diaphoretic, agitated patient in severe respiratory distress. Jugular venous distension is present at 1212 cm H2OH_2O. Cardiac auscultation reveals tachycardia and a high-pitched, blowing, early diastolic murmur best heard at the right second intercostal space. Lung auscultation reveals diffuse bilateral crackles and prominent expiratory wheezes. The right radial pulse is bounding, while the left radial pulse is absent.

ECG shows sinus tachycardia and left ventricular hypertrophy with a strain pattern, but no ST-segment elevations.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography angiography of the chest
  2. B
    Intravenous labetalol
  3. Bedside transesophageal echocardiographyCevap
  4. D
    Inhaled albuterol and intravenous methylprednisolone
  5. E
    Intravenous ceftriaxone and azithromycin

Cevap

Bedside transesophageal echocardiography
This patient's presentation of abrupt-onset tearing chest pain, asymmetric blood pressures, and unequal pulses is highly suspicious for an acute aortic dissection. The new-onset high-pitched, early diastolic murmur at the right sternal border indicates that the dissection has extended proximally to involve the aortic root, resulting in acute severe aortic regurgitation. This structural failure has precipitated acute cardiogenic shock and flash pulmonary edema (manifesting as crackles and "cardiac asthma" wheezing). In the evaluation of suspected aortic dissection, the patient's hemodynamic stability dictates the imaging pathway. For hemodynamically stable patients, computed tomography (CT) angiography is the gold standard. However, for hemodynamically unstable patients (e.g., profound hypotension), transporting the patient out of the emergency department to the CT scanner is strictly contraindicated. Bedside transesophageal echocardiography (TEE) is highly sensitive and specific for thoracic aortic dissection, can directly visualize the aortic valve, and is performed immediately at the bedside, making it the most appropriate next step.

Adım Adım Çözüm

1
Analyze the clinical presentation to identify the primary pathology.
The patient has abrupt-onset tearing chest pain radiating to the back, asymmetric blood pressures, and unequal pulses. This classic triad strongly suggests an acute aortic dissection.
Recognizing the hallmark signs of an aortic catastrophe is critical for timely intervention.
2
Evaluate the patient's hemodynamic status and complications.
The patient is in cardiogenic shock (hypotension, tachycardia) and has acute pulmonary edema (crackles, wheezing, hypoxia). The new early diastolic murmur indicates the dissection has extended proximally into the aortic root, causing acute severe aortic regurgitation.
Identifying complications (shock, acute valvular regurgitation) alters both the diagnostic and therapeutic algorithm.
3
Determine the most appropriate next step for an unstable patient.
Because the patient is hemodynamically unstable, transporting him out of the resuscitation bay for a CT scan is unsafe. Bedside transesophageal echocardiography (TEE) is the test of choice to rapidly confirm the dissection flap and evaluate the aortic valve.
Diagnostic algorithms dictate that unstable patients with suspected vascular emergencies must be evaluated at the bedside.

Anahtar Kavram

In hemodynamically unstable patients with suspected acute aortic dissection, bedside transesophageal echocardiography (TEE) is the diagnostic imaging modality of choice.
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Cardiovascular System

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