Which of the following is the most appropriate next step in management for this patient’s condition?
IV antihypertensives and CT surgery consultation (Choice A) would be the best treatment for a patient with aortic dissection. This diagnosis is characterized by severe tearing chest pain that radiates to the back, along with hypertension. Risk factors include tobacco smoking, uncontrolled hypertension, trauma (i.e. rapid deceleration), and connective tissue diseases (i.e. Marfan syndrome). Other than chest pain with radiation to the back, this patient lacks the other risk factors for aortic dissection, making Choice A less likely. IV heparin (Choice B) would be the correct choice for the treatment of pulmonary embolism and acute coronary syndrome (i.e. NSTEMI). Both of these diagnoses are possible, but a chest CT scan with PO water-soluble contrast is not the gold standard for diagnosing PE or ACS. A CT Pulmonary angiogram is ideal for PE diagnosis, and an EKG along with troponin levels are ideal for ACS diagnosis. Pericardiocentesis (Choice C) is the treatment for cardiac tamponade. The patient’s vitals show no evidence of obstructive shock, and there is no history of penetrating chest trauma, pericardial effusion, end-stage renal disease, HIV, lupus, cancer, or other risk factors for cardiac tamponade. Choice D outlines the best course of action to take in a patient with esophageal rupture, which is the disease described in the question stem. This condition can occur spontaneously after forceful vomiting causing high pressures in the esophagus (Boerhaave syndrome). In this situation, the chest pain typically begins after the onset of vomiting. Other etiologies of esophageal rupture include deceleration injuries and penetrating trauma (i.e. gunshot wounds, iatrogenic via esophagogastroduodenoscopy (EGD)). A “Hamman’s Crunch”, subcutaneous emphysema, fever, and signs of shock can be seen on exam. Diagnosis is confirmed by an esophagram or a CT scan of the chest with water-soluble oral contrast (i.e. Gastrograffin). Esophageal rupture is a life-threatening diagnosis as esophageal contents can spill into the mediastinum, causing mediastinitis and septic shock. The treatment is typically surgical with the repair of the perforated segment and drainage of fluid collections. Correct Answer: D
❓ Which of the following is the most appropriate next step in management for this patient’s condition❓CTS: Cardiothoracic Surgery, IV: intravenous. HT: hypertensive. FL: fluids, AB: antibiotics. A detailed answer will be found in https://t.co/XvqTTNtHys on Friday 11 PM UK time.— iem-student (@iem_student) September 4, 2020
Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=219641169
Nickson, C. (2019) Oesophageal Perforation. Life in the Fast Lane. Accessed August 17, 2020. https://litfl.com/oesophageal-perforation/