Delayed recognition of acute aortic dissection

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

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.

Reference event

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.

Investigation summary

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.

Safety recommendations

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.

As recommended, we considered the addition of ‘aortic pain’ as a discriminator in the Manchester Triage System (MTS). We have added this not only to the chest pain chart but also to the charts for back pain, abdominal pain and collapse.

The definition is: ‘The onset of symptoms is sudden and the leading symptom is severe abdominal or chest pain.

The pain may be described as sharp, stabbing or ripping in character. Classically aortic chest pain is felt around the sternum and then radiates to the shoulder blades, aortic abdominal pain is felt in the centre of the abdomen and radiates to the back.

The pain may get better or even vanish and then recur elsewhere. Over time, pain may also be felt in the arms, neck, lower jaw, stomach or hips.’

The update has been launched worldwide for use by all countries who have implemented (MTS) for face-to-face and telephone triage.

It has been made available in an update document on our website: www.triagenet.net. It will also be updated at next reprint in our published text books.

Response received on 17 April 2020.

Royal College of Emergency Medicine |

Royal College of Radiologists

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.

Both the Royal College of Emergency Medicine and the Royal College of Radiologists extend our sympathies to Richard’s family.

We thank them for allowing our medical specialties to learn from Richard’s death. We’re committed to developing and promoting clear guidance for diagnosing and managing patients where acute aortic dissection may be a possibility, but not recognised as such within the emergency department.

We are developing an evidence-based process for national roll-out, and the colleges have created a working group to carry out HSIB recommendations. The working group is expecting to publish its guidance in 2021.

Evidence-based protocols will provide a framework for consistency. However, Richard’s experience can only be truly avoided by ensuring that all emergency departments can access radiologists to support accurate and timely diagnosis.

This, together with the right consultant capacity within emergency departments to help the multi-disciplinary team quickly recognise signs of acute aortic dissection, will enable swift, life-saving action to be taken.

Response received on 7 October 2020.

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