Thoracic Aortic Dissection in a 38-Year-Old Man

A few days before Christmas, a flight team was activated for an interfacility transfer of a 38-year-old man with a history of hypertension and spinal stenosis diagnosed with a thoracic aortic dissection. The patient was presented to a local community hospital complaining of nearly 5 days of left-sided rib pain. This afternoon when he stood up from a chair, he experienced a near-syncopal episode. Concurrently, he had an abrupt onset of a tearing sensation in his chest that radiated to thoracic spine in the region between his shoulder blades. Ground emergency medical services (EMS) was called, and the patient was transported to the community hospital. During the initial transport and evaluation by the emergency department (ED) staff, the patient was noted to be hypertensive, with a systolic blood pressure greater than 180 mmHg.

In the ED, the patient received aspirin, morphine, and Lopressor. He underwent a chest x-ray (Figure 1) and computed tomography (CT) scan and was diagnosed with a type B thoracic aorta dissection, which was noted to start on the descending thoracic aorta distal to the left subclavian artery and extend to the level of the celiac trunk (Figure 2). Despite the initial beta blockade, the patient was noted to be profoundly hypertensive, with initial blood pressure greater than 190 mmHg systolic. The flight team was activated for hemodynamic management and rapid transport to a facility capable of vascular and cardiothoracic surgery.