Ask any trainee in emergency medicine for a list of rapidly fatal conditions, and it is almost certain that acute aortic dissection (AAD) will be near the top. In acute care medicine, AAD is a condition we think about multiple times per day.
Emergency medicine training is focused on such life threats; we are taught to think of the worst conditions first. Yet, AAD is still misdiagnosed frequently and it becomes a source of litigation on a regular basis. I take part in only a handful of legal case consultations annually, but I see cases of missed AAD heading for litigation every year.
The "classic" presentation of AAD is quite dramatic: sharp, ripping chest pain that is abrupt, with maximal intensity at its onset, radiating to the midscapular region. The classic patient at risk has the same risk factors as those for coronary artery disease, especially hypertension, and the patient typically presents quite hypertensive with pulse deficits and unequal blood pressures in the upper extremities. The chest radiograph shows a wide mediastinum. Patients with Marfan syndrome or other connective tissue diseases are also at risk. With such obvious presentations and risk factors, how can we be missing this condition?
