Emergency Ultrasound in Chest pain: Acute Aortic Syndrome Stephen Gletsu MD CCFP(EM) Department of Emergency Medicine King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia

Case 1 47 year old female CC- Chest Pain - retrosternal , radiates to mid back and epigastrium -severe , sudden onset 20 minutes prior to ED presentation PMhx- hypertension Rx- losartan - SLE atenolol - chronic renal failure amlodipine

Case 1 Physical examination vital signs - RR 18 , Sao2 100 % RA , HR 80 BP 200/95 general – alert , oriented , uncomfortable in severe pain head and neck- normal chest – AE equal , no abnormal sounds cv – no BP differential , equal pulse - normal heart sounds , no murmur abd- soft, non tender , no masses neuro- normal

Case 1 Is there an indication for ED US in this pt ?

Objectives 1)Define the Acute Aortic Syndrome (AAS) 2) evidence supporting ED US in AAS 3)technical aspects of image acquisition and review normal / abnormal images 4) limitations of ED US/AAS 5) clinical utility and suggested role for ED US in Diagnostic pathway of AAS

Acute Aortic Syndrome (AAS)

Classification of AD

Complications of AD 1)Pericardium Effusion Tamponade 2)Aortic valve Acute Regurg Card Shock 3)Coronary arteries ostial occlusion AMI 4)Carotid arteries occlusion Acute Stroke 5) Aortic branch arteries occlusion limb ischemia, paraplegia, renal/bowel ischemia 6)media/adventitia rupture Hypovol Shock

Epidemiology of AD IRAD - Relevant findings for EP 1) high mortality (1- 2%/ hour in first 48hrs ) 2)clinical presentation diverse-serious complications occur rapidly 3) classic physical findings infrequent (murmur,pulse deficit, BP differential) 4) ECG/CXR unhelpful

Epidemiology of AD IRAD - Relevant findings for EP (IRAD) 5) Type A Dissection - 2/3 of all cases type A - overall mortality - 35 % (type B 14%) - at presentation: -25% hypotensive -13% shock

Current Diagnostic Standard TEE/ CT / MRI -highly sensitive and specific “Why Bother with ED Ultrasound?” Definitive - not immediately available Testing -requires moving patient (CT,MRI) -requires intravenous contrast(CT,MRI) - requires sedation (TEE)

The Role of ED Ultrasound in AD 1)Rapidly establish diagnosis 2) Decrease time to medical Tx 3) Decrease time to definitive testing 4)Decrease time to surgical consultation/operative intervention

Evidence for ED U/S AD -Emergency Medicine literature is minimal - mostly EM case reports ( 15 cases from 6 authors , 2002 to present) 1)Perkins et al, Journal of Emergency Medicine, Nov 2008 2)Budhram et al, Academic Emergency Medicine, Dec 2008 3)Fojtik et al, Journal Emergency Medicine, Vol 32(2), Feb 2007 4)Blaivis et al,Journal Emergency Medicine, Vol 20(4),July 2002

Evidence for ED U/S AD One EM study- abstract - Sierzenski et al, Academic Emergency Medicine Vol 11(5), pp 580-581, 2004 - retrospective study- all pt w/AD over 21 months - compared those who had ED performed US to identify widened Aortic root(>3.8 cm) or intimal flap to those who did not and found statistically significant decrease in time to CT, B-blocker and OR

Evidence for ED U/S AD - Cardiology literature - most of studies on TTE in AD - introduction of TEE - Roudaut et al, Clinical Cardiology,11,553-562, 1988 - prospective study of transthoracic , suprasternal and transabdominal US in AD - 628 pt w/ suspected AD -> 128 pt confirmed AD(angio,CT,surgical,autopsy)

Evidence for ED U/S AD 1) Aortic Dilatation (sens 95%,spec 51%) Roudaut et al, Clinical Cardiology,11,553-562, 1988 - 2 echo features support dx of AD 1) Aortic Dilatation (sens 95%,spec 51%) a) Ascending Aorta- >4 cm b) Aortic arch- >3.5 cm c) Abdominal Aorta >3 ccm 2) Abnormal linear intraluminal image suggesting intimal flap(sens 67%,spec 100%) a) long ( 1 cm) - i)highly mobile, oscillating, sail- like motion ii)minimally mobile ( most frequent) parallel to aortic wall

Case 1-Parasternal Long Axis

Case 1- Suprasternal

Case 1-Abdominal aorta

ED US/AAS Probe positions 1)PSLA(+/- other cardiac views) a)Aortic Root Diameter b) Intimal flap c)Pericardial Effusion d) Global LV function 2)Suprasternal View a)Aortic arch Diameter b)intimal flap 3)Abdominal aortic view(transverse/longitudinal) a) Abdominal Aortic diameter

Parasternal Long Axis view

Suprasternal view

Suprasternal view

Suprasternal View

Abdominal Aorta-transverse

Abdominal Aorta-longitudinal

Clincal Utility of EDUS AD Rapid bedside diagnosis to expedite medical therapy, definitive imaging, surgical referral Rapid identification of high risk features of type A dissection- a) Aortic root dilatation b)pericardial effusion c ) LV dysfunction 3) Cannot rule out Aortic Dissection

Diagnostic Algorithm in AD clinical suspicion of AD EDUS-AD High Risk Not High Risk diagnostic? diagnostic? Yes No Yes No Surg cons Surg cons Medical tx TEE/CT/MRI Medical Tx +/- Medical tx Surg cons Bedside TEE Bedside TEE TEE/CT/MRI

Case 1 TEE

Cases - 2 additional cases

Summary -Transthoracic /Transabdominal US in AD is an old technique - Rediscovered in emergency ultrasound - Potential to improve outcomes and physician satisfaction in management of suspected AD