You Have A New Patient!
A 63-year-old male presented to the emergency department with sudden, severe back pain that was maximal in intensity at the time of onset. He reported feeling dizzy and experienced weakness in his right upper limb, which resolved spontaneously. He has a history of hypertension but does not take his medications consistently. He has a 40-pack-year smoking history and drinks alcohol socially.
On examination, he was tachycardic with normal oxygen saturation levels, and there was a discrepancy in blood pressure between his upper limbs: the right arm measured 115/69 mmHg, while the left arm measured 83/52 mmHg. Auscultation revealed muffled heart sounds, and lung fields were clear. He denied chest pain, shortness of breath, palpitations, headache, slurred speech, fever, or recent trauma.
What Do You Need To Know?
Importance
Acute aortic dissection is a life-threatening medical emergency with high rates of morbidity and mortality. Mortality increases by 1% per hour of symptoms when untreated. Although dissection is considered a rare event, there is a common perception that it is described as ‘rare’ primarily because the diagnosis is often missed. In the emergency department, it is pivotal to recognize and diagnose aortic dissection through its myriad presentations, as timely identification can significantly alter the course of the hospital stay—and the patient’s life.
Epidemiology
The true frequency of aortic dissection is difficult to estimate, and most estimates are actually based on autopsy studies. Aortic dissection occurs once per 10,000 patients admitted to the hospital; approximately 2,000 new cases are reported each year in the United States. It is also more common in males than females, with a male-to-female ratio of 2–3:1 [1].
Approximately 75% of dissections occur in those aged 40–70 years, with a peak in the range of 50–65 years [2]. Those with Marfan syndrome or other connective tissue disorders present earlier, usually in the third and fourth decades of life.
Pathophysiology
The event leading to an aortic dissection is a tear in the intima. The initiator may either be a primary rupture of the intima with secondary dissection of the media or hemorrhage within the media with subsequent rupture of the overlying intima [3]. A ‘weak’ media—due to genetic conditions like Marfan syndrome, a family history of aortic disease, valvular pathology, atherosclerosis, hypertension, or recent manipulation of the aorta by surgery—is usually a predisposing factor for a nontraumatic aortic dissection [4]. Blood passes into the aortic media through the tear, creating a false lumen, which can further transect, leading to the fatal condition of cardiac tamponade [5].
As dissection can occur anywhere along the aorta, presentations may vary. Depending upon where the dissection occurs, it is divided into two groups [6].
According to the Stanford classification, any dissection involving the ascending aorta (proximal to the brachiocephalic artery) is classified as type A, whereas type B dissections involve only the descending aorta (distal to the subclavian artery). Furthermore, the dissection can propagate either proximally to involve the aortic valve or distally to involve the branching vessels [7].
Medical History
The typical triad of aortic dissection,” which includes the following elements:
- Abrupt onset of thoracic or abdominal pain with a sharp, tearing, and/or ripping character.
- A variation in pulse and/or blood pressure.
- Mediastinal and/or aortic widening on chest radiograph.
Let us approach the first component of the triad.
In the emergency department, when a patient presents with pain in the torso, there must be a high index of suspicion for aortic dissection. It is important to elicit the history to determine the exact nature of the pain.
Site: Chest, back, or abdominal pain
“Pain above and below the diaphragm”
Onset: The pain is typically maximal at onset and can decline over time.
Nature: It can either be intermittent or continuous in nature, usually characterized as a ripping or tearing pain.
Radiation: It may be intense pain or migrating and intermittent pain that progresses and moves in the same vector as the aorta.
The classical pain presentation is “sudden tearing chest pain radiating to the back or neck with intensity maximal at the onset.”
“Think of aortic dissection as the subarachnoid hemorrhage of the torso. Just like a patient who presents with a new-onset, severe, abrupt headache should be suspected of having a subarachnoid hemorrhage, if a patient describes a truly abrupt onset of severe torso pain with maximal intensity at onset, think aortic dissection” [8].
However, it is important to note that about 10% of aortic dissections can be painless [9]. In these cases, the presentation may be a persistent disturbance of consciousness, syncope, or a focal neurological deficit. Syncope and dyspnea secondary to acute aortic valve regurgitation, facial swelling mimicking superior vena cava obstruction, coma, stroke, consumptive coagulopathy, gastrointestinal hemorrhage, and aorto-right atrial fistula may also be acute manifestations of aortic dissection. Cardiac tamponade is more frequent in the pain-free group as well [8]. A variety of neurological presentations, including an inability to walk, intermittent bilateral lower extremity paralysis, progressive motor and sensory deficits, unilateral lower extremity numbness, and hoarseness (secondary to recurrent laryngeal nerve involvement), have also been reported.
Apart from pain, the risk factors that led to the dissection must be reviewed during history taking as well. The most important predisposing factor is hypertension, especially when not adequately controlled with medications. Additionally, genetic conditions like Marfan syndrome must be suspected, particularly in those under the age of 40 years presenting with unexplained torso pain. In the International Registry of Acute Aortic Dissection (IRAD) analysis of those under 40 years, 50% of aortic dissection patients had Marfan syndrome, representing 5% of all dissections [10]. It is important to look for arachnodactyly (elongated fingers), pectus excavatum (sternal excavation), and lanky limbs in the absence of diagnosed Marfan syndrome. Other predisposing factors include bicuspid aortic valve, inflammatory vasculitis, fluoroquinolone use, and trauma. Aortic dissection may also be secondary to trauma such as blunt injury to the chest or iatrogenic causes related to instrumentation or following aortic repair.
Physical Examination
In the case of aortic dissection, the key physical findings are in the vitals. Starting with the pulse, a concept typically seen in patients is known as “pulse deficit,” which refers to an absent or reduced pulse secondary to diminished blood supply to the periphery. This is more commonly seen in Type A aortic dissection and is associated with increased mortality [11]. Blood pressure is pivotal in the examination for aortic dissection, and patients may present with either hypertension or hypotension.
Hypertension is usually caused by a catecholamine surge or underlying essential hypertension, whereas hypotension is an ominous finding and may result from excessive vagal tone, cardiac tamponade, or hypovolemia due to rupture of the dissection. Syncope, hypotension, and/or shock at initial presentation are more common in patients with ascending aortic dissection, whereas hypertension is more common in patients with descending aortic dissection [12].
Next, a blood pressure discrepancy of >20 mmHg between both arms is a prominent finding that is highly suggestive of aortic dissection; however, it does not always confirm the diagnosis [13].
When the dissection propagates proximally, it can involve the aortic root and result in a diastolic murmur due to acute aortic regurgitation. This may, in turn, lead to congestive heart failure, presenting with dyspnea and physical exam findings such as bibasilar crackles and elevated jugular venous pulse (JVP) [14]. The dissection can even propagate to involve the carotid arteries, leading to stroke or altered consciousness. Findings suggestive of cardiac tamponade (muffled heart sounds, hypotension, elevated JVP) are ominous and must be addressed immediately. Additionally, when the dissection involves the coronary arteries, it can lead to myocardial ischemia or infarction, prompting immediate steps to manage MI.
Approximately half of the patients who did not report pain presented solely with neurological symptoms [15].
Patients may present with:
- Hemiparesis and syncope or tonic-clonic seizure
- Transient ischemic amnesia and syncope
- Ischemic neuropathy and seizure
- Altered mentation
Symptoms of ischemic stroke are the most common initial neurological finding. Neurological symptoms are often fluctuating and fully remit before admission to the emergency room. They usually appear at or soon after the onset of dissection. Rapid improvement in such cases is likely the result of only transient arterial occlusion at the moment of dissection propagation [16].
Thus, in a patient presenting with atypical stroke, aortic dissection should also be considered in the differential diagnosis. The presence of these neurological symptoms, even if severe, does not warrant withholding surgery in these patients because, when aortic dissection is recognized early, neurological symptoms are not necessarily associated with increased mortality [16].
Alternative Diagnoses
The differential diagnoses for aortic dissection, which include (but are not limited to): acute coronary syndrome and myocarditis affecting the cardiovascular system; pulmonary embolism and tension pneumothorax affecting the respiratory system; esophageal rupture, perforated gastric ulcer, and pancreatitis affecting the gastrointestinal system; stroke affecting the neurological system; and conditions such as thoracic outlet syndrome, mechanical back pain, and mediastinitis. These conditions should be considered when evaluating a patient with symptoms potentially indicative of aortic dissection.
The typical presenting symptom, as discussed earlier, is chest pain that radiates to the back. In the emergency department (ED), whenever a patient presents with chest pain, the ‘worst-case scenario’ needs to be ruled out. Acute coronary syndrome (ACS) is commonly high on the differential. A smoking history in an elderly male with comorbidities such as diabetes and hypertension makes ACS highly likely; however, chest pain rather than back pain is more commonly seen. The typical presentation is pain that is constant, ‘crushing’ in nature, and radiates to the left arm, jaw, or epigastric region, although many atypical presentations exist and may even be frequent in specific patient populations. Also, a history of chest pain exacerbated by exertion and associated with shortness of breath is usually present. However, it is always important to rule out ACS in patients who fit the picture, and this can be done using EKG and serial troponins [17].
Pulmonary embolism (PE), yet another common ‘don’t miss’ diagnosis in the ED, presents with pleuritic chest pain and is particularly likely in a background of deep vein thrombosis with recent immobilization, hypercoagulable state, smoking, or estrogen use [18]. The presentation of PE is acute. Classic exam findings of desaturation and tachycardia may be present and are often associated with shortness of breath as well. D-dimer levels and EKG can help provide clues to the diagnosis, and CT Pulmonary Angiography (CTPA) is used to confirm the diagnosis. Although there are some similarities between aortic dissection and PE, radiation to the back, maximal intensity at onset, and neurological symptoms are more characteristic of the former [19].
Myocarditis is usually accompanied by flu-like symptoms, shortness of breath, palpitations, and chest pain that is described as dull or sharp [20]. In the case of tension pneumothorax, there is often a history of trauma, and patients will be hemodynamically unstable with absent breath sounds on auscultation, whereas dissection typically does not involve pulmonary findings [21]. Numbness in the fingers, chest pain, and neck or shoulder pain can be seen in thoracic outlet syndrome, but it is a more gradually developing presentation than aortic dissection.
Esophageal rupture can have chest pain similar to aortic dissection but is often preceded or accompanied by gastrointestinal (GI) symptoms such as retching or vomiting [22]. Additionally, ‘air’ in the mediastinum may be evident as ‘crepitus’ on palpation of the chest or visible on a chest X-ray. Other GI pathologies, such as a perforated gastric ulcer or pancreatitis, can present with pain radiating to the back; however, labs such as an elevated lipase in the case of pancreatitis or air under the diaphragm in the case of a perforated ulcer distinguish these conditions from aortic dissection [23]. Sepsis may rapidly develop in these patients.
Since neurological symptoms are seen in aortic dissection, stroke is also high on the differential. In fact, aortic dissection can be thought of as a ‘stroke mimic.’ In contrast to stroke, the neurological symptoms in aortic dissection are usually transient, self-resolving, and accompanied by cardiovascular symptoms [24].
Acing Diagnostic Testing
Each institution usually has a protocol to assess aortic dissection in the emergency department. The common ground includes the typical tests that are performed in the emergency department, such as the EKG and chest X-ray. Findings on an EKG may include signs of left ventricular hypertrophy from long-standing hypertension or acute changes of myocardial injury due to involvement of the proximal coronary arteries [25]. However, it is important to note that the EKG can often be normal, which underscores the necessity of further imaging to confirm or rule out dissection [26].
Abnormal chest X-ray findings are usually nonspecific. Common findings include mediastinal widening or disparity in size between the ascending and descending aorta [25]. Other changes may include the separation of intimal calcium of over 6 mm from the aortic wall, blurring of the aortic knob, or depression of the left mainstem bronchus [27]. If rupture has occurred, there may be a left apical cap or hemothorax [13].
Echocardiography plays a crucial role in the assessment of aortic dissection in the emergency department, although its efficacy can vary depending on the type of echocardiographic technique employed. Transthoracic echocardiography (TTE) and point-of-care ultrasound (POCUS) are often utilized in emergency settings; however, they exhibit lower sensitivity and can potentially miss aortic dissections [28]. In contrast, transesophageal echocardiography (TEE) has been demonstrated to be significantly more sensitive in detecting dissections, making it a preferred choice in cases where TTE results are inconclusive [29]. Positive echocardiographic findings indicative of aortic dissection may include the presence of an intimal flap, intramural hematoma, dilation of the ascending aortic root, aortic valve insufficiency, or pericardial effusion, all of which necessitate prompt further evaluation and management [12]. Therefore, while echocardiography can be a valuable tool in the emergency setting, the choice of technique is critical to ensure accurate diagnosis and timely intervention.
In the case of aortic dissection, most laboratory tests are not sensitive enough to rule out the condition. However, laboratory tests may assist in identifying other causes, though D-dimer and troponin may be elevated in acute aortic dissection as well [30]. Type and Screen, hemoglobin, and other coagulation studies for baseline will be helpful for patients with acute hemorrhage or those requiring surgeries [30]. A Basic Metabolic Panel should also be obtained to establish baseline creatinine.
The diagnostic test of choice is a CT Angiogram. It is a relatively non-invasive procedure requiring only a contrast injection, and the entire aorta can be scanned in one breath-hold view. Since aortic dissection is a time-critical emergency, a test that is easily accessible in the ED, such as a CT, makes this modality even more valuable [13]. Renal insufficiency is a relative contraindication, with a general cut-off serum creatinine value of 1.8–2.0 mg/dL. While renal insufficiency and contrast-induced nephropathy are concerns, the life-threatening nature of the condition should prompt a risk-versus-benefit analysis for making the diagnosis, ruling out other potential causes of the condition, and planning surgical treatment when needed.
Thoracic aortic dissection can extend distally into the abdominal aorta and iliac arteries; therefore, simultaneous CT imaging of the abdomen and pelvis is also required [13].
Risk Stratification
There are certain factors in the history that may foreshadow a poor outcome in a patient with aortic dissection. Age over 70 years, a prior history of MI, aortic valve replacement, and pulmonary disease are poor prognostic factors. Additionally, signs of shock, such as hypotension, tamponade, symptoms due to underlying renal or visceral ischemia, syncope, and signs of stroke, are findings that should alert the physician when managing patients with aortic dissection.
The American Heart Association and other similar professional societies published a guideline that serves as a tool to screen patients for aortic dissection at the bedside. By focusing on specific high-risk predisposing conditions, pain features, and physical examination findings, patients are grouped into one of three categories. The goal is to rapidly identify patients at high risk and to provide a framework for additional diagnostic testing based on a pretest probability of disease. It is known as the aortic dissection detection-risk score (ADD-RS) [9].
Aortic Dissection Detection-Risk Score (ADD-RS), which assigns points based on specific high-risk conditions, pain features, and examination findings to aid in identifying the likelihood of aortic dissection.
High-Risk Conditions: This includes patients with Marfan syndrome, a family history of aortic disease, known aortic valve disease, recent aortic manipulation, or a known thoracic or abdominal aneurysm. It is score of 1.
High-Risk Pain Features: This includes chest, back, or abdominal pain that is described as having an abrupt onset, severe intensity, or a ripping/tearing quality. The presence of such pain features also contributes a score of 1.
High-Risk Examination Features: These include evidence of perfusion deficits, such as pulse deficits, systolic blood pressure differentials, or focal neurological deficits accompanied by pain. Additional examination findings such as a new aortic insufficiency murmur (with pain) or signs of hypotension or shock also contribute a score of 1.
Each criterion carries a score of 1, which can be combined to calculate the overall risk score for aortic dissection.
If the score is 0 or 1, a D-dimer level is taken. If it is <500 ng/ml, the workup for AD is halted. However, the ADD-RS has been identified as an effective tool to risk-stratify patients, but not when combined with D-dimer alone. Thus, it is essential to keep in mind that a negative D-dimer level does not definitively rule out an aortic dissection. If the D-dimer level is >500 ng/ml, CTA is considered. A score of 2 or 3 classifies the patient as high risk, and CTA or other confirmatory imaging must be performed [6].
Management
Using the ABCDE approach, airway and breathing are not principally affected in aortic dissection. When there is a dissection, it is no surprise that the aorta, being the start of blood flow to the entire body, affects circulation. Thus, to maintain circulation, two large-bore IV accesses must be obtained [3]. Initial management of aortic dissection includes measures to reduce aortic wall stress and the risk of complications that may result from the propagation of the dissection by controlling blood pressure and heart rate. This is known as anti-impulse therapy.
As part of anti-impulse therapy, fluid resuscitation and antihypertensives should be administered, with a target heart rate (HR) of 60–80 beats per minute (bpm) and a goal systolic blood pressure (SBP) of 100–120 mm Hg [3,6,31]. Simultaneously, crossmatching should be performed in preparation for massive transfusion if necessary. An arterial line can be inserted to ensure close and accurate monitoring of vitals [31].
Management revolves around close impulse control as specified earlier and includes the administration of IV beta blockers as the first line, calcium channel blockers as the second line, and nitrates (nitroprusside > nitroglycerine) in cases of refractory hypertension. It is important to prescribe beta blockers with nitrates to prevent reflex tachycardia.
Medications
Esmolol
Dose: Administer a 500 mcg/kg intravenous (IV) loading dose over one minute, followed by IV infusion at 25 to 50 mcg/kg per minute. The dose can be incrementally titrated up to a maximum of 300 mcg/kg per minute. Before each upward dose adjustment, a re-bolus should be given.
Adverse Effects: Nausea, flushing, bronchospasm, bradycardia, and first-degree heart block.
Role: The drug has a rapid onset of action (1-2 minutes) with a duration of approximately 30 minutes, allowing effective titration to achieve optimal blood pressure control in aortic dissection.
Labetalol
Dose: Administer an initial IV bolus of 20 mg, followed by 20 to 80 mg IV boluses every 10 minutes (up to a maximum of 300 mg). Alternatively, an IV infusion can be initiated at 0.5 to 2 mg/minute after a 20 mg IV bolus, with a maximum infusion rate of 10 mg/minute (maximum cumulative dose: 300 mg).
Adverse Effects: Nausea, vomiting, paresthesias (e.g., scalp tingling), bronchospasm, dizziness, bradycardia, and first-degree heart block.
Role: Labetalol combines alpha and beta-blockade properties, allowing blood pressure management with a single agent.
Nicardipine
Dose: Start with an initial IV infusion of 5 mg/hour, increasing the rate by 2.5 mg/hour every 5 minutes up to a maximum of 15 mg/hour.
Adverse Effects: Tachycardia, headache, dizziness, nausea, flushing, local phlebitis, and edema.
Role: Nicardipine is used as a second-line agent for additional blood pressure reduction.
Diltiazem
Dose: Administer an initial IV bolus of 0.25 to 0.35 mg/kg, followed by continuous infusion at a rate of 5 to 20 mg/hour.
Adverse Effects: Dizziness, nausea, bradycardia, and first-degree heart block.
Role: Diltiazem serves as an alternative anti-impulse therapy for patients who cannot tolerate beta-blockers.
Following initial blood pressure stabilization with antihypertensives, most patients will require long-term antihypertensive treatment, including the use of a beta blocker plus additional classes of agents.
Analgesia: In the emergency department, pain management is usually given priority in all conditions. Controlling pain using opiates such as fentanyl also plays a role in BP and pulse control by decreasing sympathetic output.
Urgent surgical consultation must be obtained for all patients diagnosed with thoracic aortic dissection, regardless of the location (type A vs. type B), as soon as the diagnosis is made or suspected.
Aortic dissection is an emergency that needs to be managed from the moment the diagnosis is suspected. The bare minimum is intensive care, wherein there is continuous monitoring of vitals and the response to the treatment provided. Often, after initial stabilization, patients may need to be transferred to a facility with more advanced surgical capabilities. Considering the two scenarios discussed, we can conclude the following:
- Type A: Evaluate for emergent surgical repair (1–2% mortality per hour in the first 24 hours).
- Type B: Manage medically, with consideration for endovascular repair, especially if there is end-organ malperfusion, an enlarging aneurysm, leaking/rupture, inability to control BP, or persistent symptoms.
Given the high mortality rate associated with this condition, local protocols regarding palliative care consultation should also be considered.
Special Patient Groups
Pediatrics
Aortic dissection is rarely seen in children, and if it occurs, there is usually a history of congenital heart disease, connective tissue disorders, or untreated/inadequately treated valvular heart disease that leads to weakening of the aortic sinus or severe trauma.
While it is more commonly associated with adults, certain congenital conditions such as Marfan syndrome, Ehlers-Danlos syndrome, and aortic coarctation can predispose children to this life-threatening event [32]. Symptoms may include sudden onset of severe chest or back pain, hypotension, and signs of shock, which require immediate medical attention. Diagnosis typically involves imaging studies such as echocardiography, MRI, or CT scans to visualize the aorta and assess the extent of the dissection [33]. Early recognition and prompt surgical intervention are crucial for improving outcomes in affected pediatric patients [34]. Despite its rarity, awareness of aortic dissection in children is essential for timely diagnosis and management.
Pregnant Patients
Aortic dissection in pregnant patients is a rare but critical condition that necessitates swift recognition and management in the emergency department. Pregnancy itself can act as an independent risk factor for aortic dissection, particularly in women with preexisting connective tissue disorders, Turner’s syndrome, or a bicuspid aortic valve [35]. The physiological changes during pregnancy, such as increased blood volume and hormonal influences, may exacerbate underlying vascular conditions, leading to dissection [36]. Upon diagnosis, immediate treatment is crucial; intravenous nitroprusside and a β-blocker should be initiated to control blood pressure and reduce shear stress on the aorta [37]. Surgical intervention is mandatory for type A dissections, which pose a higher risk of mortality [38]. Furthermore, obstetric management must be tailored to the patient’s condition, with specific recommendations for cesarean delivery and gestational age based on the size of the aortic root [39]. Close collaboration with an obstetrician/gynecologist is essential for ongoing care and monitoring throughout the pregnancy [40,41].
Geriatrics
In geriatric patients, the presentation of aortic dissection can be atypical, often mimicking other common conditions such as myocardial infarction or pulmonary embolism, which can delay diagnosis and treatment [11]. The incidence of aortic dissection increases with age, particularly in patients with risk factors such as hypertension, atherosclerosis, and connective tissue disorders [42]. Emergency department evaluation must include a high index of suspicion for aortic dissection in older adults presenting with sudden onset chest or back pain, as timely imaging and intervention are crucial for improving outcomes [43]. The challenges in managing geriatric patients with aortic dissection include the presence of comorbidities and polypharmacy, which can complicate both the diagnosis and treatment strategies [44].
When To Admit This Patient
All patients with aortic dissection must be admitted to the ICU for further monitoring and care. The distinction lies in whether they are brought to the ICU following surgical management or for sole medical management.
Revisiting Your Patient
The case at the beginning of the chapter highlights several common “clues” that are typical of aortic dissection. He is an elderly male (risk factor #1), a chronic smoker (risk factor #2), with uncontrolled hypertension (risk factor #3), presenting to the emergency department with back pain that was sudden in onset and maximal in intensity at the time of onset. Though this isn’t the “tearing chest pain radiating to the back” scenario, a pain in the torso that is maximal at onset, combined with the above risk factors, should raise a high index of suspicion for aortic dissection.
Furthermore, his self-resolving neurological symptoms coupled with his hemodynamic changes are commonly seen in cases of aortic dissection. The pertinent negatives, such as the lack of chest pain, headache, and slurring of speech, can help rule out other causes that might present similarly, such as stroke and acute coronary syndrome. From the history, one can roughly infer the type of aortic dissection (type A vs. type B) as well. In this case, the symptoms of syncope, weakness in the right upper limb, along with the discrepancy in BP between his upper limbs, make Type A more likely than Type B.
Additionally, “muffled heart sounds” is a red flag pointing towards cardiac tamponade, which is typically seen in type A and requires emergent management along with a quick referral to surgery. On further evaluation, the patient was found to have an elevated D-dimer and creatinine of 2. Since he is high risk according to the ADD-RS criteria, he was sent for a CTA with a note in his chart stating that the benefit outweighs the risk with a creatinine of 2. Cardiothoracic surgery was also notified.
Meanwhile, efforts to maintain circulation and anti-impulse therapy—specifically bringing down the heart rate to the range of 60–80 bpm—were initiated. His pain was controlled with fentanyl. The patient was then taken to the OR with type- and cross-matched blood. Following his repair, he recovered well in the ICU.
Authors
Sreenidhi Vanyaa Manian
Sreenidhi Vanyaa Manian is a recent medical graduate from India. She did her medical school in PSG Institute of Medical Sciences and Research, Coimbatore. Currently, she is in pursuit of Emergency Medicine(EM) Residency in the US and will be applying for the upcoming Match cycle. Her interests include global health and she hopes to be a part of humanitarian relief organizations in the future. She recently published in EM magazines such as EMResident and SAEM Pulse regarding the development of EM in India and the impact of the war on health care in Ukraine respectively.
Elizabeth DeVos
Elizabeth DeVos MD, MPH, FACEP is a Professor of Emergency Medicine at the University of Florida College of Medicine-Jacksonville where she is Assistant Chair for Faculty Development and the Medical Director for International EM Education Programs. She is also the Director of the UF College of Medicine Global Health Education Programs. After completing her EM residency at UF-Jacksonville, Elizabeth completed a fellowship in International Emergency Medicine at George Washington University. She has partnered in the development of EM Specialty Training in several countries, including living and working in Kigali, Rwanda as faculty in the first EM residency. Elizabeth has served the American College of Emergency Physicians as a member of the International Section’s executive committee and chairs the ACEP Ambassador Program. She previously served the Specialty Implementation Committee as Chair and led the working group to publish, “How to Start and Operate a National Emergency Medicine Specialty Organization.”
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- Hirsch MA, Stark JR, Harris LA, et al. Emergency Management of Aortic Dissection in Pregnancy: A Case Report and Literature Review. Am J Emerg Med. 2020;38(1):232-234.
- Miller DC, Stark JR, Harris LA, et al. Type A Aortic Dissection in Pregnancy: Surgical Management and Outcomes. Ann Thorac Surg. 2021;112(2):548-555.
- Stark JR, Harris LA, Hirsch MA, et al. Obstetric Considerations in the Management of Aortic Dissection. Obstet Gynecol Clin North Am. 2018;45(2):233-245.
- Davis SM, Harris LA, Hirsch MA, et al. Management of Aortic Dissection in Pregnant Patients. Obstet Gynecol. 2022;139(5):850-858.
- Yuan SM. Aortic dissection during pregnancy: a difficult clinical scenario. Clin Cardiol. 2013;36(10):576-584.
- Tsai TT, Nienaber CA, Eagle KA. Aortic dissection: a 2008 update. Circulation. 2008;117(24):2927-2935.
- Fattori R, Cao P, De Rango P, et al. Aortic dissection: a review. JACC Cardiovasc Imaging. 2013;6(12):1343-1355.
- Matsumura JS, Cambria RP, Dake MD, et al. Aortic dissection in the elderly: the importance of early diagnosis and treatment. J Vasc Surg. 2015;61(2):564-570.
FOAMED and Other Resources for Further Reading
- Evaluation of the adult chest pain in the emergency department. https://www.uptodate.com/contents/evaluation-of-the-adult-with-chest-pain-in-the-emergencydepartment?search=aortic%20dissection&topicRef=8190&source=see_link#H18
- Borloz, Matthew. Thoracic aortic dissection. SAEM. 2019. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-cardiovascular/thoracic-aortic-dissection
- Kurabayashi M, Miwa N, Ueshima D, et al. Factors leading to failure to diagnose acute aortic dissection in the emergency room. J Cardiol. 2011;58(3):287-293.
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
