Aortic Dissection Diagnosis & Missed Diagnosis Dr Ruth Large Emergency Physician Waikato DHB

Chest pain in the Emergency Department Chest pain is a very common presentation The job of the Emergency Doctor is to recognise and exclude the life threatening causes. Most patients who present with chest pain to the ED will be discharged home. Serious causes for chest pain are many and include: heart attack, blood clot to lungs, lung collapse, chest infection, rupture of the food-pipe, fluid on the heart or lungs. In almost all life threatening causes of chest pain the patient looks terrible.

Chest Pain: What happens in the ED Triage... by a trained triage nurse. Chest pain = Triage category 2 Immediate ECG Blood tests Chest X-ray

So how do we decide what to do? Clinical suspicion Examination Investigations

How do doctors make a diagnosis?

Clinical suspicion Patient history: Risk factors Pain Other symptoms Immediate “bed-o-gram”

Examination General appearance Blood pressure Lung exam Heart exam Neurological exam Abdomen exam

https://choosingwisely.org.nz/patients-consumers/ Investigations https://choosingwisely.org.nz/patients-consumers/ Blood tests D-Dimer test ECG Bedside Echo Chest X-ray CT scan

Putting it all together Clinical suspicion with high risk features Abrupt onset Variation in pulse Abnormal X-ray Aortic Dissection risk score What else could it be? Heart attack, blood clot, heart valve problem, inflammation of the heart, fluid on the heart.

So why does it sometimes go wrong?