Case 2 - Don't flap!
Author: Nish Cherian Reviewer: Nick Mani
A 64-year old non-English speaking woman presents to ED at 2am with a sudden onset of chest and abdominal pain. She is agitated and writhing around on the trolley. She is hypertensive 180/70 and tachycardic 115bpm, but other vitals are normal.
You are concerned about the possibility of an acute aortic syndrome and there is at least a 2h wait for CT. POCUS shows the following:
Clip 1. Transverse view of abdominal aorta
Clip 2. Long axis view of abdominal aorta
Clip 3. Subcostal view of abdominal and descending aorta
Clip 4. A
Clip 4. B
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An intraluminal intimal flap of the abdominal aorta
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Applying colour flow Doppler would demonstrate flow in the true lumen (see Appendix)
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Suprasternal view - obtained by placing transducer in suprasternal notch with markers in approx 1 o’clock position aiming caudally.
It demonstrates the aortic arch and descending aorta. The innominate and subclavian arteries are seen to branch off the aortic arch.
There is no clear intimal flap seen.
Note: POCUS is not sensitive enough to exclude thoracic aortic dissection and a CT aortic angiogram must be obtained. However it can help rule in the diagnosis and facilitate early BP control and specialty consultation.
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Parasternal long axis (PLAX) - the descending aorta is seen just deep to the LA. The aortic root can also be measured in this view (>4cm is abnormal)
Parasternal short axis (PSAX) - a slightly modified PSAX view by fanning the transducer may reveal the descending thoracic aorta in long axis.
Case resolution
The patient was moved to the Resus room and started on a labetalol infusion pending CT. CT angio confirmed a type B dissection which was medically managed and she had a good outcome.
Appendix
Colour flow Doppler showing flow in true lumen of abdominal aorta
