Non - traumatic emergencies - Experience from a tertiary care centre In Karachi

To review the incidence, clinical presentation and outcome of Non traumatic Aortic emergencies in a tertiary care hospital and its evaluation in the Emergency department [ED]. We conducted a retrospective review of cases presented to the ED at Aga Khan University Hospital during 15 year period [1988 - 2002] who had final diagnosis of Aortic Dissection or Ruptured Aortic Aneurysm. Patients without confirmatory investigations were excluded. We aimed at looking for the incidence, clinical presentation, evaluation in the ED and final outcome. Of the 12 cases, 7 had aortic dissection while the remaining 5 had ruptured aortic aneurysm. For Aortic dissection, mean age of presentation was 53 years with male predominance. Most of these patients had chest pain. Most common comorbid condition was hypertension. Pulse deficit was found in 2 cases, murmur in 4 cases, and focal neurologic deficit in 2 cases. Electrocardiogram revealed ischemic changes in 3 cases. Widened mediastinum on chest x-ray was present in all cases. The only initial misdiagnosis was cardiac ischemia. One patient survived to discharge. For patients presenting with ruptured aortic aneurysm, mean age of presentation was 52 yrs with a male predominance. The associated comorbid condition was hypertension. Almost all patients presented classically with abdominal pain, hypotension and palpable mass. No patient survived to discharge. Aortic emergencies although rare, are associated with significant mortality. High index of suspicion and prompt recognition by the emergency physician is of key importance

Acute dissection of the thoracic aorta: experience at the Puerto Rico Medical Center (1991 through 1995)

BACKGROUND: Acute dissection of the thoracic aorta has a very poor prognosis unless promptly diagnosed and treated. The clinical presentation, diagnosis and management of 16 patients was reviewed. METHODS: We identified 12 patients from the Puerto Rico Medical Center and 4 patients from the Centro Cardiovascular de Puerto Rico y del Caribe whose diagnosis was made from January 1991 to December 1995. Medical records and autopsy reports were reviewed. RESULTS: Of the 16 patients, 10 [62%] were males, 10 [62%] were 60 years old or older [range 25 to 85 years], and 15 [93%] had a past history of hypertension although only 6 [38%] were found with an initial blood pressure of 140/90 or higher. Chest pain was the initial symptom in 13 [81%]. Of these 46% [6/13] described it as oppressive, with radiation to back or neck in 38% [5/13]. In none a neurological abnormality was the initial presentation. No physical sign was present in more than 40% of patients. One patient had a diastolic murmur suggestive of aortic regurgitation but none had a pericardial rub or a neurologic deficit. The electrocardiogram showed left ventricular hypertrophy in 35% but none had changes compatible with an acute Q wave infarction. The chest radiography was compatible with dissection in all in whom it was done [8/8]. Computerized tomography of the chest was diagnostic in 6 of 8 patients [sensitivity 75%]. Aortography had a sensitivity of 80% [4/5]. Trans-thoracic echocardiogram was diagnostic in 3 of 4 patients [75% sensitivity]. Transesophageal echocardiogram had a 100% sensitivity [2/2]. In 8 patients [50%] the correct diagnosis was made by postmortem examination, all of whom died within 24 hours of Emergency Room's evaluation. Of those properly diagnosed 5 died without being surgically intervened. Only one survived surgery [1/3] Overall mortality was 93%. The most common pathological finding was Type A dissection in 14 [88%]. Cardiac tamponade was found in 9 [56%]. Hemothorax was found in 6 [38%]. Aortic valve insufficiency was reported in 20% and coronary artery involvement in 28%. CONCLUSIONS: The dismal prognosis traditionally associated with acute dissection of the thoracic aorta remains unchanged. Prompt diagnosis based on high clinical suspicion. followed by expeditious medical and surgical treatment are fundamental to change the natural course of this condition