Immediate recognition of a dissecting Aorta
Submitted by Anthony Ragnauth
Tags: dissecting Aorta emergency recognition RRT
A particularly interesting patient I had recently comes to mind when thinking about clinical judgement. Patient JS, a 44 year old gentleman, came in by ambulance complaining of upper back pain. Upon entering the room I immediately recognized this was not a simply strained muscle, but a true medical emergency.
After briefly introducing myself to JS, I could see he was in a tremendous amount of pain, so much so, that he couldn’t lay still for even a second to obtain an EKG. No matter how many different positions he tried to lay, he could not decrease his pain. His skin was diaphoretic as he described the sudden onset of pain and feeling like his shoulder blades were tearing apart. After hearing him describe his symptoms and his clinical presentation, I was extremely suspicious that his aorta was dissecting. The pain of an artery tearing itself apart is a unique and characteristic presentation that looks nothing like any kind of typical back pain I have ever seen.
The emergency physician walked in shortly after I began get JS prepared for evaluation. I recognized the importance of exposing and monitoring the patient and did so without delay. Assistance was utilized in getting the patient on monitor while I established IV access. The only way a provider can truly diagnose an aortic dissection is with a CT angiogram, which is why I obtained access right away and delegated other team members to have the radiology department ready with an available CT scanner.
JS had family with him. His wife and sons were present and were naturally very nervous. I facilitated their presence with the patient for his emotional comfort and theirs. The attending physician was professional in explaining her concerns as to what was going on with JS to his family. After the physician discussed the overall plan of care with the family, I then educated them on how the plan would actually take place, what we would be doing to manage JS during the initial workup, and what to expect in terms of the ER process. This alleviated many of their concerns and fears as to what to expect next.
We had JS on the CT table, and our suspicions were confirmed that he had a grade B dissection. I explained to JS and his family as I wheeled him back to the trauma bay about a vascular surgeon coming to see him and medication we were going to start him on to control his blood pressure and the reason why we doing this. I advocated for more pain control for JS while he waited on his consult, he was much more comfortable after a heavy dose of Fentanyl and very grateful. Through this relatively brief encounter, I established a strong rapport with JS and his family and was able to help alleviate many of their concerns as to what to expect. They even jokingly asked if they could keep me as their nurse while he was in the ICU. While I know it was a joke, I took it as a great compliment to what I was able to do for them in their critical time.