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BACKGROUND
Paramedics bring a 56-year-old man with severe chest
pain to the emergency department. The patient had a
brief loss of consciousness at home, which prompted his
wife to call for help. He had a "significant" decrease
in blood pressure after the paramedics gave him
nitroglycerin en route. He appears to be in severe
distress, restlessly moving in bed and sitting up and
clutching his chest and upper abdomen. He speaks only
Korean, and further history cannot be obtained.
On physical examination, the patient's temperature is
normal, but his heart rate is 110 beats per minute, and
his blood pressure is 210/112 mm Hg in the right upper
extremity. His respiratory rate is not discernible. On
neck examination, jugular venous distension (JVD) cannot
be accessed because the patient is unwilling to lie
down. Cardiac examination reveals no murmur, rub, or
gallop. Normal S1 and S2 heart sounds are heard. He has
normal breath sounds with good air movement. He has no
tenderness to palpation, distension, or pulsatile mass
on abdominal examination. His back is unremarkable for
flank tenderness.
The ECG is normal except for sinus tachycardia on
bedside interpretation. Routine studies for chest pain,
including chest radiography and laboratory
investigations, are ordered.
The emergency physician decides to perform bedside
sonography partly because of the limited history
available, the language barrier, and the clinical
concern about an aortic disaster. Images 1-2 are the
transverse and longitudinal views of the abdominal
aorta, respectively. A suprasternal image is also
obtained (see Image 3).
What does this last image of the thoracic aorta show?
What is the diagnosis and treatment? |
Hint
The sonograms are of both the abdominal aorta and the
thoracic aorta. |
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Author:
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D. Brady Pregerson, MD,
Attending Physician, Department of Emergency Medicine, Cedars Sinai
Medical Center; Author,
Quick
Essentials: Emergency Medicine and
Pharm
Animals Pharmacopoeia (www.ERpocketbooks.com) |
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eMedicine Editors:
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Ada Jain Kumar, MD, Department
of Radiology, Evanston Northwestern Healthcare
Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine,
Section of Emergency Medicine, Department of Surgery, Attending
Physician, Medical Director, Department of Emergency Services, Yale-New
Haven Hospital
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