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

2. 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.

3. 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

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

5. How do doctors make a diagnosis?

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

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

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

9. 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.

10. So why does it sometimes go wrong?