Aorta

Saccular AAA with Dissection Flap.

Contributor: Daniel Ostapowicz, MD

Flap seen in the descending aorta consistent with aortic dissection

Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate)

Patient presented with severe chest pain and concerning ECG without STEMI. A faint dissection flap can be seen in the aorta on this transverse view in the subcostal region.

Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM

Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH

View his original post here

A chest pain received an echo and showed evidence of a dissection in the PLAX, PSAX, and AP4C views within the descending aorta.

Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM

Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH

View his original post here

Patient presented with symptoms of stroke. Echo revealed pericardial effusion and aortic US showed a dissection flap emphasizing the importance of POCUS prior to TPA.

Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM

Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH

View his original post here

61 year-old male presented with one day history of generalized abdominal pain, nausea, and vomiting. He was hemodynamically stable (BP 130/59); EKG notable for the presence of U waves and lateral ST depressions; labs revealed a negative troponin, potassium 3.1, lactic acid 5.4. Abdominal POCUS seen here revealed an abdominal aortic dissection flap as his unifying diagnosis.

Richard Cunningham, MD. Emergency Medicine

An elderly male with hypertension and DM presents with C/O chest pain. Bedside ultrasound performed demonstrating a dissection flap in the lumen of the abdominal aorta. A subsequent parasternal long axis show extension into descending thoracic aorta as well.

Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM

Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH

View his original post here.

A 60 year old man was transferred to a trauma facility after presumed mechanical ground-level fall. He was only able to answer yes/no questions, vital signs were normal and stable upon arrival. He denied abdominal or back pain.

Upon arrival to receiving facility, POC ultrasound revealed intimal flap within the abdominal aorta extending from the subxiphoid region to the common iliac arteries. Bedside echo revealed no aortic root dilatation, pericardial effusion, or evidence of tamponade. CT scan confirmed thoracic and abdominal aortic dissection. Cardiothoracic surgery was notified immediately.

POCUS can play a critical part in allowing for rapid diagnosis and can expedite patient-care, particularly in patients with altered mental status who cannot provide a more robust history.

Quinn Fujii, DO
Desert Regional Medical Center, Emergency Medicine

Patient with abrupt onset chest pain radiating to back. Normal ECG and Troponin. POCUS revealed dissection flap within abdominal aorta.

Nishant Cherian
Emergency Medicine Registrar

50 y/o M w/ hx of HTN p/w sudden onset upper back pain. POCUS found dissection flap in the descending aorta in both parasternal long view and abdominal aorta. The diagnosis of aortic dissection was quickly confirmed by CT. Given the importance of timely diagnosis with aortic dissection, POCUS allowed rapid and non-invasive diagnosis of a potentially tricky diagnosis, and facilitated expedited treatment and transfer to a cardiothoracic surgery center.

Dr. Robert Allen - Kings County Emergency Medicine

Aortic dissection carries an incredibly high mortality that increases 1%/hour. POCUS can be used as a rule-in test to quickly identify this life threatening diagnosis. If a dissection is not seen on POCUS, CT angiography should still be performed because the sensitivity of POCUS is not as high as for other indications. 

The spine can be used as a landmark - the echogenic stripe with shadowing in the midline. The aorta is the large vessel anterior and slightly to the right of the spine. In this image an intimal flap can be seen in the anterior third of the aorta consistent with an aortic dissection. The IVC cannot be clearly visualized in this image but would normally be left, less pulsatile, with a less echogenic vessel wall. Non-visualization of the IVC is most often due to bowel gas or compression of the abdomen with the probe. 

Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A dissection flap can clearly be visualized.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A dissection flap can clearly be visualized with color flow around it.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A pulsating dissection flap can clearly be visualized.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

60s M PMH HTN, CKD stage 3 presented with bilateral flank pain x2 days. CT of the abdomen/pelvis with IV contrast showed a 3.8 cm x 4.6 cm infrarenal AAA with a 3.1 cm L internal iliac aneurysm. POCUS of the aorta was obtained re-demonstrating the AAA. Dedicated CTA showed that there actually demonstrating aneurysmal dilation of the descending thoracic aorta with a thrombosed type B dissection. The patient was managed with aggressive blood pressure and heart rate control with esmolol and was admitted to the ICU for medical management.

Dr. Henrik Galust, PGY4, Denver Health Residency in Emergency Medicine

Dr. Nimish Bhatt, Fellow, Denver Health Ultrasound Fellowship