Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection

Am J Emerg Med. 2016 Mar;34(3):486-92. doi: 10.1016/j.ajem.2015.12.005. Epub 2015 Dec 12.

Abstract

Study objective: Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD.

Methods: We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality.

Results: Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27).

Conclusions: Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.

MeSH terms

  • Aortic Aneurysm, Thoracic / diagnosis*
  • Aortic Aneurysm, Thoracic / diagnostic imaging
  • Aortic Aneurysm, Thoracic / mortality
  • Aortic Dissection / diagnosis*
  • Aortic Dissection / diagnostic imaging
  • Aortic Dissection / mortality
  • Autopsy / statistics & numerical data
  • Diagnostic Errors / statistics & numerical data*
  • Echocardiography, Transesophageal / methods*
  • Emergency Medical Services / methods
  • Emergency Medical Services / standards
  • Emergency Medical Services / statistics & numerical data
  • Emergency Medicine / methods*
  • Emergency Medicine / standards
  • Emergency Medicine / statistics & numerical data
  • Female
  • Humans
  • Male
  • Medical Records / statistics & numerical data
  • Middle Aged
  • Multi-Institutional Systems / statistics & numerical data
  • Multicenter Studies as Topic
  • Outcome Assessment, Health Care / statistics & numerical data
  • Retrospective Studies
  • Time Factors
  • Tomography, X-Ray Computed