You’re working a shift when you see a 90-year-old man with crushing chest pain check-in. What are you thinking? What are you worried about? In this episode, Andy and John are joined by guests Geoff Comp, DO, and Carissa Tyo, MD at ACOEP Spring Seminar 2023 to discuss how they would navigate this case.

Initial Case

The patient presents from home where he was having dinner with his family. He began having sudden onset chest pain and upper abdominal pain. He did not finish eating and came straight to the ED. He was able to walk in through the lobby with his wife and his grandson. You obtain a little more history and find out that he still drives and has a job at a local convenience store. He has a history of hypertension and is not taking his prescribed medications. He has a remote history of myocardial infarction and according to his family has “something in his chest that they were watching, but they stopped caring about it 10 years ago.” The patient and his wife are primarily Spanish-speaking.  He is alert and oriented x 4. 

Vitals: HR 105, BP (right arm) 250/195, BP (left arm) 185/100, RR 16

Now what?

Given this case, what are your initial thoughts? What is your differential diagnosis? Were you thinking of aortic dissection, acute coronary syndrome, ventricular aneurysm, hypertensive emergency pulmonary embolism, gastritis, and esophageal rupture? It is important not to anchor in cases that truly start to sound like one diagnosis. When broadening it can be helpful to think of other body systems that may be involved.

What kind of testing would you do? On arrival, the patient was placed on the monitor and IVs were established. An EKG was performed and was normal. Labs including CBC and CMP were drawn and are pending. Ultrasound was used to perform a RUSH exam to look at the heart and lungs. On bedside ultrasound, the patient had a low ejection fraction. 

If you were thinking of aortic dissection, you were correct! What medication(s) would you start? If you clinched the diagnosis from the beginning, you may have started esmolol, however, if you initially were treating hypertensive emergency, you may have started with nitroglycerin instead. 

The patient was then sent to CT to further characterize the problem, but the team had a pretty good idea at that point what was going on based on the patient’s constellation of symptoms, so they began calling the transfer center as the hospital the patient was at did not have cardiothoracic surgery in house. 

The patient was found to have a 14 cm dissection and was actively bleeding into his chest. Transport was going to take some time. Who do you call? Trauma surgery, if you have them? The Chaplin? In this case, the Chaplin was called to be there for a different kind of goals of care conversation than we as ED doctors are used to having. If the patient said he wanted everything done, he may make it to definitive care and be just fine. On the other hand, if he coded before he could get to definitive management he would certainly die and no amount of resuscitative efforts would be able to bring him back.

This case highlights the importance of advanced directives and the importance of our job as ED doctors to be able to have these tough goals of care conversations with patients and their families. 

Unfortunately, the case ended with transport arriving and the patient coding before he could be transported to definitive care. Was that a blessing in disguise? What if healthcare were perfect and we could snap our fingers to get our patients whatever they needed?  

Take-Home Points:
  • Vital signs are vital.
  • If someone stops eating to come to the ED, it’s probably pretty serious
  • Getting a good succinct history is crucial to making a diagnosis
  • Advanced directives are so important and it is important that we feel comfortable having goals of care conversations with families because we will be forced to have them whether we like it or not. 
  • Storytelling in medicine is so powerful. Being vulnerable helps yourself and others learn and grow.

Post by Patricia Capone, DO PGY-2 

About Our Guest:

Geoff Comp, DO
Assistant Program Director, Creighton University School of Medicine/Vallwywise Health Medical Center (Phoenix) Emergency Medicine Residency

Carissa Tyo, MD
Associate Professor of Clinical Medicine, Residency Director, Combined EM/IM Program at Univesity of Illinois Health

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