Rapid Response

Patient on the precipice

Richard Hamilton, age 67, is admitted to the telemetry unit from the emergency department (ED) with new-onset chest pain. In the ED, his troponin test is negative, a 12-lead ECG is unremarkable, and a chest X-ray shows a calcified aorta. The ED physician orders a computed tomography (CT) scan of the chest. Mr. Hamilton smokes cigarettes and has a history of hypertension and hyperlipidemia. His home medications include lisinopril, hydrochlorothiazide, and atorvastatin.

History and assessment hints

When Mr. Hamilton returns to his telemetry room after the CT scan, he’s diaphoretic and breathing rapidly. You find him anxious, dyspneic, and complaining of severe pain in his chest and between his shoulder blades. You quickly obtain his vital signs: blood pressure (BP) 190/100 mm Hg; respiratory rate 36 breaths/minute, heart rate 120 beats/minute, and oxygen saturation 90%. You find his lungs clear and peripheral pulses strong.

Mr. Hamilton tells you his pain came on suddenly. He describes it as a tearing sensation in his chest radiating to his back. Concerned he could be experiencing an aortic dissection (AD), you immediately call the rapid response team (RRT).

On the scene

When the RRT arrives, you summarize your findings. The team administers 4 L oxygen by nasal cannula and begins infusing 0.9% normal saline solution. The physician orders a 12-lead ECG to rule out acute myocardial infarction, along with morphine 2 mg I.V. for pain and labetalol 20 mg I.V. to lower the patient’s BP. The radiology department reports Mr. Hamilton’s CT scan shows an AD of the descending thoracic aorta. The RRT adds a second large-bore I.V. line, orders more blood work, and transfers the patient to the intensive care unit for aggressive BP control.

Outcome

Once Mr. Hamilton’s BP and heart rate stabilize, he’s placed on an oral beta blocker and transferred back to the telemetry unit. He does well and is discharged 1 week later.

Education and follow-up

In AD, the aortic layers separate or tear longitudinally. This allows blood to flow between the layers, resulting in a dissection, or false lumen. Blood diverts from the circulation into the false lumen, causing an expanding mass that obstructs and reduces blood flow to the surrounding area and organs. Cardiac output and endorgan perfusion decrease.


Risk factors include hypertension, smoking, atherosclerosis, hyperlipidemia, and genetic disorders. Recognizing AD signs and symptoms early is crucial, as rapid progression can lead to an irreversible outcome. In about one-third of patients, aortic rupture causes death.

AD can be hard to diagnose because signs and symptoms may mimic those of other conditions, like acute coronary syndrome and stroke. Typically, patients present with sudden-onset chest or abdominal pain, which may radiate to the back; they commonly describe it as sharp, tearing, and severe. BP may differ between arms.

The Stanford AD classification system labels ascending aortic dissections as type A and all others as type B. Type A dissections are surgical emergencies. Fortunately, Mr. Hamilton has a dissection of the descending aorta (type B), which usually can be managed medically. Such management aims to decrease systolic BP to a range of 100 to 120 mm Hg and to lower the heart rate below 60 beats/minute. Beta blockers best achieve these goals because they slow the heart rate, decrease the force of left ventricular contraction, and reduce pressure in the false lumen. Opioids usually are given to manage pain and halt pain-induced increases in BP, heart rate, and oxygen demand.

Your quick actions and those of the RRT helped Mr. Hamilton avoid disaster. On discharge, you caution him not to undertake strenuous physical activity until his first follow-up physician visit. You advise him he’ll need to make lifestyle changes, including eating a low-cholesterol diet, getting regular exercise, and adhering to lifelong hypertension management. You also teach him how to monitor his BP and tell him that at-risk family members should be screened for aneurysm. Finally, you refer him to a smoking cessation program.

Cindy Ruiz is a clinical nurse specialist in critical care at Northwest Community Hospital in Arlington Heights, Illinois.

Selected references

Black JH, Manning WJ. Management of acute aortic dissection. Updated September 28, 2016.

Leitman IM, Suzuki K, Wengrofsky AJ, et al. Early recognition of acute thoracic aortic dissection and aneurysm. World J Emerg Surg. 2013; 8(1):47.

Mercer-Deadman P. Aortic dissections, aneurysms and ruptures: an emergency perspective. Can J Emerg Nurs. 2014;37(1):18-21.

White A, Broder J. Acute aortic emergencies—part 1: aortic aneurysms. Adv Emerg Nurs J. 2012;34(3):216-29.

White A, Broder J, Mando-Vandrick J, Wendell J, Crowe J. Acute aortic emergencies—part 2: aortic dissections. Adv Emerg Nurs J. 2013;35(1):28-52.

Black JH, Manning WJ. Management of acute aortic dissection. Updated September 28, 2016.

Leitman IM, Suzuki K, Wengrofsky AJ, et al. Early recognition of acute thoracic aortic dissection and aneurysm. World J Emerg Surg. 2013; 8(1):47.

Mercer-Deadman P. Aortic dissections, aneurysms and ruptures: an emergency perspective. Can J Emerg Nurs. 2014;37(1):18-21.

White A, Broder J. Acute aortic emergencies—part 1: aortic aneurysms. Adv Emerg Nurs J. 2012;34(3):216-29.

White A, Broder J, Mando-Vandrick J, Wendell J, Crowe J. Acute aortic emergencies—part 2: aortic dissections. Adv Emerg Nurs J. 2013;35(1):28-52.

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