Chest Pain in a Patient With Hypertensive Emergency

Case Study

A rapid response event was initiated by the bedside nurse for new-onset, severe chest pain. Upon prompt arrival of the rapid response team, it was found that the patient was a 47-year-old male with a known history of insulin-dependent diabetes mellitus, hypertension, and substance abuse. He was admitted a few hours earlier for altered mental status and bizarre behavior, and a urine toxicology screen was found to be positive for cocaine and methamphetamines. The patient had developed acute onset, sub-sternal, 10/10 chest pain 10 min before the rapid response event was initiated. The pain was stabbing and radiating to his back. He was nauseous but denied any other symptoms.

Vital Signs

Temperature: 100°F, axillary
Blood pressure: 240/135 mmHg
Pulse: 145 beats per min (bpm) – narrow complex tachycardia on telemetry
Respiratory rate: 32 breaths per min
Pulse oximetry: 97% oxygen saturation on room air

Focused Physical Exam

The patient was a middle-aged male sitting up in bed in severe distress. His respiratory exam showed tachypnea and labored breathing, but the lungs were clear to auscultation. A cardiac exam showed tachycardia with a regular rhythm; no murmurs were identified. No edema was present. The abdominal exam was benign.

Interventions

A cardiac monitor was attached. A stat electrocardiogram (EKG) was obtained, which showed sinus tachycardia; no ST changes related to acute ischemia were present. The patient was given 2 mg IV morphine for pain. He was also given 10 mg IV labetalol for elevated blood pressure, and a stat bedside chest X-ray was obtained. Chest X-ray showed a widened mediastinum indicating aortic dissection. The patient was started on esmolol infusion, and a stat computed tomography (CT) angiogram of chest and abdomen per dissection protocol was ordered. Imaging was consistent with dissection of the descending thoracic aorta ( Fig. 3.1 ). An emergent consult was called to thoracic surgery, and the patient was transferred to the intensive care unit for further management.

Final Diagnosis:

Acute Aortic Dissection secondary to hypertensive emergency

Acute Aortic Dissection

Aortic dissection is a life-threatening, catastrophic illness caused by a tear in the tunica intima of the aorta; this leads to the entry of blood into the wall of the aorta under pressure, creating a false lumen that creates a separation between the aortic wall layers. Aortic dissection can be classified anatomically based on the location of the pathologic condition. Two classification systems are used, as shown in Table 3.1 .

Table 3.1

Anatomical classification of aortic dissection

Classification system	Subtypes
Daily (Stanford) classification system	Type A – Dissection involving the ascending aorta and/or arch of the aorta, regardless of distal extent
Daily (Stanford) classification system	Type B – Dissections distal to the arch of the aorta
DeBakey classification system	Type 1 – Intimal tear originating in the ascending aorta and involvement of aortic arch or beyond
	Type 2 – Intimal tear originating in the ascending aorta, dissection confined to the ascending aorta
	Type 3 – Intimal tear originating in the descending aorta and involvement of the aorta only beyond the origin of the left sub-clavian artery

Aortic dissection can be classified clinically based on the duration from symptom onset to presentation: hyperacute (<24 h), acute (1-14 days), subacute (15-90 days), and chronic (>90 days). The dissection can also be classified as complicated vs. uncomplicated, based on the presence of complications such as proximal or distal malperfusion, rapid expansion, impending rupture or frank rupture of the aortic wall, hypertension refractory to three or more classes of maximum doses of anti-hypertensives, or uncontrolled pain. The dissection can also be classified according to location ( Fig. 3.2 ).