3: Kasumi Apayo
Medical Mystery Case 3: “Kasumi Apayo” Chest Pain
A 56 year old male is brought to the emergency department with chest pain, syncope and a drop in blood pressure after receiving nitroglycerin. The patient speaks only Korean and there is no translator. You pull out your copy of “Side-Kick: Emergency Medicine” to establish a few critical details and discover the patient has no known medical problems, medications or allergies. “Kasumi Apayo”: his chest hurts.
On exam he is in severe distress demonstrating Levine’s sign and also holding his epigastric area. Pulse is 60 and BP is 90/60. The pulse ox is 100%. Lungs are clear. Heart is regular without murmur. You think all pulses are equal except the left DP which seems decreased.
His EKG is normal except for LVH, and his CXR is showns a borderline mediastinum. You decide to take a quick look at his aorta with the ED ultrasound machine.   What does the image below show? What is your next step? Who do you call and when? What further imaging should be performed? How will you treat this patient?
(Scroll down for answer)
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ANSWER:
Aortic Dissection (Type A). Here is the longitudinal view.
The CT scan below was confirmatory for a type A dissection.
Excerpt on Aortic Dissection from “Quick Essentials“
Symptoms: Pain: max at onset:85%, sharp>tearing, migrate, to back
transient CNS, syncope:10%…
Signs: HTN: 50%, low BP: 5%, AI murmur: 30%, bruits,
pulse deficit: 15% (20%nl pts: BP dif > 20). Oft atypical
Risks: HTN, Marfans, FH(19%), Ehlers-Danlos, Pregnancy, Cocaine,
recent Angiogram, temporal arteritis
Rx: Empiric: 2%/h die; call surgeon early; propraolol > NTP:
Goal: HR=60 & BP=100, T&Cx10
W/u: Echo: 60/80: effusion?, CT: 95+, MRI: 98, Angio: 80,
Transesophageal Echo: 95+
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