In the ED, their vitals/exam are as above. Concern for {Blank single:19197:: “aortic dissection +/- intramural hematoma “,”symptomatic AAA +/- rupture”} given patient’s abrupt onset {Aortic Dissection:41855} especially considering history of {Risk factors for aortic dissecion/AAA:48153}.

Differential diagnosis is broad but includes aortitis (with potential etiologies including giant cell arteritis, takayasu arteritis, syphilis, mycobacterium, neoplasia), acute coronary syndrome, pulmonary embolism, arrhythmia (such as atrial fibrillation) with clot embolism, PTX (albeit less likely at this time as patient with bilateral breath sounds), esophageal perforation (albeit less likely given without crepitus and pain with swallowing), mediastinitis (albeit less likely given patient without history of recent surgery/infection), pericarditis (albeit less likely given lack of characteristic EKG findings).

Given the five ways patients die from aortic dissection (1. Hypovolemia from aortic rupture, 2. Tamponade from dissection into pericardium, 3. AMI [+/- cardiogenic shock] from dissection into coronaries, 4. Neurological death from dissection -> clot -> stroke, 5. Organ failure from lack of perfusion), will proceed as below.

– Labs/Tests:
— EKG
— BSUS looking for: A) pericardial effusion suggestive of tamponade, B) Abdominal aorta > 3cm (starting at epigastrium), C) aortic insufficiency via aortic root >3cm on parasternal long view, D) intimal flap in aortic arch via suprasternal view
— Pulse/BP/SaO2% on both arms
— Labs including lactate, CBC, CMP, Lipase, Troponin x2, BNP, D-Dimer, ESR/CRP (elevated inflammatory markers may suggest aortitis), Coags, T&S, Serum tox, UTox
— Place arterial line in radial artery with higher blood pressure for hemodynamic monitoring (avoid arm with lower BP as likely falsely low BPs due to dissected artery; avoid femoral line given may need to be accessed by surgery/can give falsely low BPs if dissection involves iliacs)
– Imaging: CXR looking for mediastinal widening, CTA chest/abdomen/pelvis (consider also including CTA of head/neck)
– Treatments:
— Esmolol gtt for goal HR <60 (Diltiazem PRN/gtt if adverse reaction to beta-blockers or additional HR control needed) --- Clevidipine (preferred given more rapidly titratable)/Nicardipine gtt for goal SBP 100-120 (Use Nitroglycerin gtt if additional BP control needed) --- Prepare 10 units pRBCs --- If hypotensive, activate massive transfusion with low threshold for phenylephrine (avoid norepinephrine/phenylephrine given want to avoid increasing HR/impulse against intimal wall) --- IVF as needed, pain control as needed, antiemetics as needed - Consults: Cardiac surgery if Stanford Type A (ascending aorta), Vascular surgery if Stanford Type B (descending aorta) - Dispo: Likely admission to *** surgery