Some important considerations when working up chest pain that will make us think of a thoracic aneurysm.
Check out the paper mentioned
Habib M, Lindström D, Lilly JB, D'Oria M, Wanhainen A, Khashram M, Dean A, Mani K. Descending thoracic aortic emergencies: Past, present, and future. Semin Vasc Surg. 2023 Jun;36(2):139-149. doi: 10.1053/j.semvascsurg.2023.04.009. Epub 2023 Apr 30. PMID: 37330228.
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Let's dissect a reflection. Hello and welcome to this week's urgent bite brought to you by the Royal New Zealand College of Urgent Care. My name is Guy Melrose and today I've been thinking about thoracic aneurysms. A while back I had a case of thoracic dissection present through urgent care and I've been pondering it ever since. I think it was about as classic a case as I've ever seen, sudden onset of pain in the upper abdomen and chest radiating through to the back, the word tearing was used and the sternotomy scar on the chest was of concern. I later learned that there had been a previously identified aneurysm but that was not mentioned in the history. Clinically the patient looked awful, sweaty and in pain. They had an almost 40mm of mercury drop in systolic blood pressures between arms and there was a pulse deficit felt at the wrists. Large bore IV access twice, fluids, morphine and a priority one ambulance had them feeling better and off to hospital pretty quickly and a dissecting aneurysm was confirmed there. Now this case has sat on my mind for a while now and not because anything went wrong in our management or diagnosis. Indeed it was an incredibly smooth and well managed case that was as classic as a textbook. The reason it's been playing on my mind is the fact that these cases are not always classic and I wanted to reflect on the approaches to making a diagnosis particularly in urgent care. I also wondered if there was any way to risk stratify and exclude these in urgent care. I guess I was wanting to consider the grey cases that might come through, the less obvious and I wanted to see if I could determine some key take home points to focus my mind on potential cases in the future. So in my reflections I came upon a great paper from the seminars of vascular surgery published in June of 2023 and written by Habib et al and it was titled Descending Thoracic Aortic Emergencies Past, Present and Future. It is open access and it's a good read. While it talks about the classifications and management of thoracic aneurysms, the bit that is relevant to urgent care is the diagnosis and imaging section. So it starts off by saying clinical diagnosis is challenging and in part this is due to the similarity with ischemic heart pain. But they go on to discuss the use of D-dimer and indeed they reference the aortic dissection detection risk score tool, the AD-DRS, which is available on MD-Calc. This tool has three categories, a score of one or less, a D-dimer can be used to exclude without imaging, a score of two or three, needs a CT. On initially reading this I thought that maybe this could be a useful tool for urgent care but on further reflection I think that this tool is more useful as a means of considering potential thoracic dissections for us and should be used in urgent care to strengthen our referrals. I do not think urgent care is the right place to be doing a D-dimer in these situations partly because of the availability to a rapid test result and also due to urgent care not being the best place for someone to wait for this result. I would say that if you're considering the diagnosis the patient should be in an emergency department with a vascular surgeon nearby in case they deteriorate. Indeed this paper says that sudden death is often the first and only sign of aortic pathologies. So despite reading that D-dimer is used in a risk tool I think that this tool is for ED use but if you use the details in what is a very simple scoring tool I think you'll be making the right considerations when it comes to a potential thoracic aneurysm presenting to urgent care. So as I said the A-D-D-R-S has three sections. High-risk conditions, high-risk pain features and high-risk examination findings. Reviewing these is a great refresher and what should be going through our minds when assessing someone with chest pain when a dissecting aneurysm could be a differential. So the high-risk conditions are malfans or other connective tissue diseases so I'd imagine Ellers-Danlos would be the one that we would encounter the most. A family history of aortic disease which I think is tricky to always establish in urgent care. Known aortic valve disease or thoracic aortic aneurysm or a recent aortic manipulation. So these are the important history items for us to ask for or establish from existing notes and anyone with these would get a point on the A-D-D-R-S scoring system. The next section is high-risk features. These are chest, back or abdominal pain that is abrupt in onset and described as tearing or ripping and is severe and that gets you one point. And then high-risk examination features are a pulse deficit, systolic blood pressure difference between arms, focal neurological deficit, a new murmur or hypotension or shock, again one point for any in that category. So I think reviewing these risk features used in the A-D-D-R-S tool gives us a good grounding for making the consideration of pain being related to thoracic aneurysm. My patient would have scored a three but as I said they were never going to be referred anywhere other than the hospital very quickly. But I think that the features highlighted in this risk score are useful for us to use in urgent care when working up a chest pain and may support a concern for an aneurysm rather than an ischemic chest pain. As mentioned before I do not think urgent care is the setting for us to be using the D-dimer to exclude due to the potential for the patient to deteriorate. But those of you who work in E-D might consider using it. But my reflections have resulted in a few personal take-home points. Firstly the value of the words tearing and ripping when describing pain through to the back. These words should have us very concerned. Secondly family history, personal history and connective tissue disorders including bar fans need to be established in all of our histories when encountering chest pain. And finally I saw this in my case and that is the pulse deficit and systolic variance between the arms. So that being an established risk factor means that we should be feeling both pulses and doing blood pressures in both arms in all cases of chest pain that we see. So these are the important take-homes that I've had in regards to what is a relative rare yet rapidly fatal condition. Differentiating between cardiac and dissection pain can be difficult. So I think in reality we're going to be in the process of referring these patients through four chest pain work up at the hospital anyway. But I think it's important we focus maybe on our history taking and some of those examination points to maybe start to make a clearer differential a little bit earlier. And finally as the great British news reporter Sir Trevor McDonald would say I wanted to make a quick mention about the benefit of personal reflection and how it can form and guide your CPD. For busy clinicians getting through the day and returning to your family is probably high on your priorities and rightly so. But one of the ways that I find helps me learn the most and indeed forms the premise for most of the podcast topics we cover in the urgent bites is reflection. And this isn't necessarily reflecting on cases that went badly although that is a strong way to learn. It can be on any case that you see. A brief period of thought about the case and asking of yourself a question related to that case can lead to a quick PubMed search and then the acquisition of a new bit of information or the strengthening of your prior knowledge. And in this case I've just been mulling this over for some time now. I did not do all my reflecting in one go but I made a note and I kept revisiting it every now and then and pondering it. So I guess my point is that our CPD and ongoing learning can fit in with busy lives and reflection need not be a formal process of sitting down and studying. It can happen when you're in a waiting room or while on a walk or driving a car. Contemplation is reflection and allowing your mind to wonder and find answers is a satisfying and effective way to learn. As someone who listens to these weekly ramblings of mine chances are you are a fan of CPD or at least someone who can tolerate my ideas such as to claim your CPD time. But if you can develop a reflective habit not just in medicine but in all areas of your life I think you'll find benefit in the way you acquire knowledge and the way that knowledge sticks in your brain. So I think it's a good idea to keep a reflective diary or a notebook and allow your mind and thoughts to ponder not just today but like a good whiskey let it age and see what happens. I was once told by a physics teacher that if you could not solve a question go to sleep and in the morning your brain will have found the answer and this rings true for CPD but not just overnight it can be months of pondering but I think it really is worth it. I've linked to the paper mentioned and the MD-Calc page on ADD-RS in the show notes. If you have any comments, questions, corrections or suggestions please email podcast at rnzcc.org.nz and we'll be back again next week with another podcast. I look forward to seeing you all then but for now, thanks for listening. [Music] [BLANK_AUDIO]
