Chest Pain Patient

Maybe pass on the aspirin. Kinda worrisome for dissection.
 
Brandon O said:
Maybe pass on the aspirin. Kinda worrisome for dissection.
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Dissection is more common in males, and she's a bit on the young side to have one. Apparently no Hx of connective tissue problems, no trauma, no Hx of HTN.
On the other hand, her whole family has died of cardiac issues, and she's in the danger zone for that age-wise.

Obviously I could be wrong, but I strongly disagree? It just seems SO much more likely to be something cardiac or a PE, IMO. Not giving aspirin seems really bad to me here.
 
Gurby said:
Dissection is more common in males, and she's a bit on the young side to have one. Apparently no Hx of connective tissue problems, no trauma, no Hx of HTN.
On the other hand, her whole family has died of cardiac issues, and she's in the danger zone for that age-wise.

Obviously I could be wrong, but I strongly disagree? It just seems SO much more likely to be something cardiac or a PE, IMO. Not giving aspirin seems really bad to me here.
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None of that is really dispositive, but I agree that by odds I'd probably lean toward PE. I think the only real error would be not considering it.

I'd go to nearest facility as long as they have full imaging capabilities and don't suck. Serial ECGs will help too. We can spitball on the risk/benefit of the aspirin thing... wonder if anyone has any data on risk ratio in TAD.
 
Brandon O said:
None of that is really dispositive, but I agree that by odds I'd probably lean toward PE. I think the only real error would be not considering it.

I'd go to nearest facility as long as they have full imaging capabilities and don't suck. Serial ECGs will help too. We can spitball on the risk/benefit of the aspirin thing... wonder if anyone has any data on risk ratio in TAD.
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Heart disease killed 600,000 people in 2010. I couldn't find any data on aortic dissection, but wikipedia says they occur at a rate of ~3/100,000 people per year. It doesn't say how many of those people die, but let's just assume they all die for simplicity's sake... Given US population of 3 million we can estimate that 90 people died of dissections in 2010 (though this is probably an overestimate)...

You had better have a damn good history if you're going to withhold aspirin from this patient because you suspect dissection. I don't think there's anywhere close to enough evidence here. If she had a connective tissue disorder or one ran in the family, then maybe it'd be worth a call to med control... And I expect they'd just tell you to give the aspirin anyways.

Aspirin is one of the few drugs we have that really truly has a lot of evidence backing it up. I really don't think we can withhold it because we think maybe we found a zebra. And really there is barely anything here to point towards dissection.

Maybe someone else can chime in here? It feels completely insane to me to even consider aortic dissection as an actual possibility, much less let that alter your treatment for this patient given her presentation, history and family history.
 
The balance of risk is in favour of giving aspirin.

A small dose of aspirin is not going to be clinically significant if the patient has an aortic dissection (now, if we gave thrombolysis then perhaps) but if it's not an aortic dissection but myocardial ischaemia and we don't give aspirin then yes, it would be clinically significant.
 
Gurby said:
Aspirin is one of the few drugs we have that really truly has a lot of evidence backing it up. I really don't think we can withhold it because we think maybe we found a zebra.
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This is a good argument and I might agree (although to be complete we should acknowledge that the benefit of aspirin, while real and well-demonstrated, is not large; around 1 in 40 will benefit).

And really there is barely anything here to point towards dissection.
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Well, older patient with sharp CP radiating to the back, syncope, dyspnea, "head" complaints (i.e. stuff perfused from the aortic arch), unclear but extensive cardiac hx in the family, generally ill-looking and hypertensive. Nothing clear on the 12-lead except some possible inferior ischemia. Nothing convincing but one should wonder.


It feels completely insane to me to even consider aortic dissection as an actual possibility
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This is the one thing I do disagree with. It's our job to consider infrequent but deadly differentials, whether or not we end up disregarding them.
 
Clare said:
There is an argument that could be made for being guided by automatic interpretation at EMT level however it's not overly strong given the limitations and differences between monitor software

True...yet in my region, our tx plans (for this scenario) (emt or paramedic) are the same with the exception of pain management. In addition, we have only 1 facility to transport to.
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