Aortic Dissection

This case was written by Dr. Martin Kuuskne who is one of the editors-in-chief at EMSimCases and is an attending Emergency Medicine Physician at University Health Network in Toronto.

Why it Matters

Aortic Dissection is one of the most deadly causes of chest pain for the emergency physician. Its presentation, methods of diagnosis, management and complications are varied and demand critical thinking, clear communication and teamwork. This case highlights the following points:

  1. The key elements of the history, physical exam and initial investigations that support the diagnosis of aortic dissection.
  2. The importance of managing hypertension in the setting of aortic dissection, including specific blood pressure and heart rate targets.
  3. The need to set priorities dynamically as a patient becomes unstable and requires ACLS care.

Clinical Vignette 

You are working the day shift at a tertiary-care hospital. A 66-year-old female is being wheeled into the resuscitation bay with a history of a syncopal episode. No family members or friends are present with the patient.

Case Summary

A 66-year-old female with a history of smoking, HTN and T2DM presents with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She will become increasingly bradycardic and hypotensive, requiring the team to mobilize resources in order to facilitate diagnosis and management of an aortic dissection.

Download the case here: Aortic Dissection

First EKG for the case: Sinus tachycardia

(EKG Source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Second EKG for the case:

mobitz-1-stemi

(EKG Source: http://hqmeded-ecg.blogspot.ca/2012_09_01_archive.html)

CXR for the case:

(CXR Source: https://radiopaedia.org/articles/aortic-dissection)

Ruptured Ectopic

This case is written by Dr. Kyla Caners. She is a PGY5 Emergency Medicine resident at McMaster University and is also one of the Editors-in-Chief here at EMSimCases.

Why it Matters

Ectopic pregnancy is a can’t miss diagnosis in Emergency Medicine. This case highlights just how sick patients with ruptured ectopic pregnancies can be. Some important learning points include:

  • The importance to having an approach to the undifferentiated patient with syncope and hypotension
  • The need to order a βHCG in women of child-bearing age who present with syncope
  • The rapid stabilization of a patient with intraperitoneal hemorrhage using massive transfusion.

Clinical Vignette

26 year old female presents after a syncopal episode at home. She immigrated from Cambodia two weeks ago to work as a live-in nanny, but has been feeling unwell for the last 3 days. The patient speaks limited English, but the family she is staying with said she has been vomiting the past few days and was unable to get out of bed this morning. When she tried, she because quite dizzy and then passed out.

Case Summary

26 year-old female, recently immigrated from Cambodia, presents after a syncopal episode at home. At the case outset, she complains of feeling “a little dizzy” and has a HR of 100 and a BP of 90/60. Once the team initiates care, the patient will say she has to vomit and then become poorly responsive and more hypotensive. The patient does not know that she is pregnant, so the team will have to consider the diagnosis early and use bedside U/S to point them in the right direction. The team will then need to initiate a massive transfusion and arrange for surgery. If the ectopic pregnancy is not recognized, the patient will become persistently more hypotensive until she has a PEA arrest.

Download the case here: Ruptured Ectopic

RUQ U/S for the case found here:

RUQ FF

Abdominal U/S with no IUP for the case found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

ECG #1 for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

ECG #2 for the case found here:

normal-sinus-rhythm

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)