Acute aortic dissection is a relatively rare but life-threatening condition. It requires rapid recognition and urgent treatment in a specialist centre. The symptoms and signs can be confusing and aortic dissection may be mistaken for other conditions, leading to delay in diagnosis.
Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care.
The reference event for this investigation was the case of a 54-year-old man who experienced chest pain during exercise.
He was initially taken to the emergency department of a non-specialist acute hospital. After over four hours in the hospital, the diagnosis of acute aortic dissection was confirmed.
The patient was sent by ambulance to a specialist centre for treatment but died on the way there.
This investigation is the second of two parts based on this event. The first part, ‘Transfer of critically ill adults’, was published in January 2019. This part seeks to understand the factors affecting the recognition of acute aortic dissection, including the role of the emergency department.
The aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital.
Our investigation identifies a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.
It also highlights that once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present.
The investigation explores decision-making processes in the emergency department and ways these might be improved, particularly when the diagnosis is uncertain.
We’ve made two safety recommendations as a result of this investigation. One to the Manchester Triage International Reference Group and one to the Royal College of Emergency Medicine.
We expect a response to the safety recommendations within 90 days of publication of the investigation report. The responses will be shared here when they’re available.
Manchester Triage International Reference Group
It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.
Royal College of Emergency Medicine
It is recommended that the Royal College of Emergency Medicine, together with the Royal College of Radiologists, develops, deploys and evaluates a national evidence-based process to detect and manage patients with acute aortic dissection presenting to emergency departments. The process should form part of a wider strategy for managing non-cardiac chest pain in the emergency department.
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