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Point-of-care ultrasound in patients with aortic dissection – two year experience at Ljubljana Emergency Medical Unit

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Background

Aortic dissection (AD) is associated with high morbidity and mortality; mortality rates increase by 1-2% per hour1, therefore timely diagnosis is pivotal. Point-of-care ultrasound (PoCUS) narrows the number of differentials in patients with shock, chest pain and shortness of breath2; however, reports addressing its routine use in the ER are scarce.

Objective

Retrospective assessment of factors influencing use of PoCUS and its impact on time-to-diagnosis in patients with AD.

Patients and methods

We reviewed medical records and charts of patients with confirmed diagnosis of acute AD between May 2010 to May 2012.

Results

Twenty-seven patients (out of 45.630 presenting to the ER) with AD were identified (19 type A, 8 type B; 13 with typical clinical presentation). Diagnosis was confirmed with contrast enhanced CT in 25 patients, and with PoCUS (during CPR) and autopsy in two. 14 (52%) had prior PoCUS (11 confirmed, 3 supported the diagnosis). PoCUS did not affect time-to-discharge from the ER significantly (87, 60-120 vs. 120, 102-240 minutes, p=0.179). PoCUS was performed more often in unstable patients (100 vs. 38.1% stable, p=0.09) and in patients with equivocal clinical presentation (30.8% vs. 71.4% in typical presentation, p=0.038). On a multivariate model, atypical clinical presentation emerged as an indenpedent predictor of PoCUS use after adjustment for age, gender, and hemodynamic stability (p=0.047).

Conclusion

Our findings suggest that point-of-care ultrasound is increasingly used in the initial ER management of patients with AD, especially in hemodynamically unstable patients and in patients with atypical clinical presentation.

References

  1. 1.

    Agnostopoulos CE, Prabhakar MJS, Kittle CF: Aortic dissections and dissecting aneurysms. Am J Cardiol 1972, 30: 263–71. 10.1016/0002-9149(72)90070-7

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    Jones AE, Tayal VS, Sullivan DM, Kline JA: Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004, 32: 1703–8. 10.1097/01.CCM.0000133017.34137.82

  3. 3.

    von Kodolitsch Y, Schwartz AG, Nienaber CA: Clinical prediction of acute aortic dissection. Arch Intern Med 2000, 160: 2977–82. 10.1001/archinte.160.19.2977

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    2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010,121(13):1544–1579.

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Author information

Correspondence to Hugon Možina.

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Open Access This article is distributed under the terms of the Creative Commons Attribution 2.0 International License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Keywords

  • Chest Pain
  • Emergency Medicine
  • Interventional Radiology
  • Multivariate Model
  • Timely Diagnosis