Emergency Medicine Claims Case Study: Aortic Dissection
January 28th, 2019
Kathy Krolak, MSA, BSN, RN-BC
Aortic dissection is the most common catastrophe of the aorta, often resulting in fatal consequences. When a patient experiences aortic dissection, blood surges through a tear in the aortic intima with separation and creation of a false lumen, or channel. The dissection may occur anywhere along the aorta and extend proximally or distally into other arteries.
Early detection and treatment of this complication is critical to survival, as one-fifth of patients die before reaching the hospital, and up to one-third die from operative or perioperative complications.
Peak incidence of this condition occurs in adults aged 50 to 65, and existing hypertension is a significant contributing factor. Timing is critical for effective treatment, so ED physicians should stay alert to potential signs and symptoms of aortic dissection, particularly the abrupt onset of tearing chest or back pain. If aortic dissection is determined to be a potential diagnosis, the physician can order imaging tests, such as transesophageal echocardiography, CT angiography, MRI, and contrast aortography to confirm. Treatment always involves aggressive blood pressure control and serial imaging to monitor progression of dissection. Surgical repair of the aorta and placement of a synthetic graft may also be necessary, depending on the location of the dissection.
In this study, we examine two cases of undiagnosed aortic dissection that resulted in negative consequences, and we offer tips to avoid similar outcomes.
A 35-year-old male presented to the ED with complaints of chest pain and diaphoresis. He was examined by our insured physician, who initiated a full chest pain work-up. Tests included an ECG with normal results, a chest x-ray that revealed mild heart enlargement but showed no signs of congestive heart failure/pneumonia, and various labs that showed mildly elevated white blood count and troponins.
The physician also noted a systolic murmur and ordered a CT angiogram, revealing an 8.1 cm ascending aortic aneurysm. He then called for a cardiothoracic surgery (CTS) consult, but the in-house cardiothoracic surgeon was in surgery and directed the insured to call his partner at another hospital. The ED physician spoke with the partner and reported all pertinent facts but neglected to mention the murmur. The patient was accepted for transfer at 4:33 p.m.
The surgeon gave no additional orders or recommendations, and the physician then requested a cardiology consult. Cardiology examined the patient, labs, and images and entered a diagnosis of thoracic aneurysm without dissection, ordering that the patient be transferred urgently to the accepting hospital. Cardiology also documented a diastolic murmur but entered no additional orders for medications, labs, or imaging. The patient signed a consent for transfer at 6:06 p.m., and a bed became available at 6:25 p.m. The patient left the ED around 7:25 p.m. and expired prior to arrival at the accepting hospital as a result of aortic dissection.
A 46-year-old male presented to the ED with complaints of chest pain. He described this pain as feeling like he had been “shot in the chest by a 45-caliber rifle.” He was seen by our insured physician, who ordered a cardiac work-up and a d-Dimer to rule out pulmonary emboli. Both results returned negative.
Following a chest x-ray, the radiologist noted, “Mild right suprahilar mediastinal fullness is favored to be largely created by portable AP technique. No acute disease seen.” Our insured ED physician reviewed the chest x-ray, but he indicated that he ultimately relied on the radiologist’s interpretation. The patient was given pain medication and discharged with a diagnosis of muscle strain. The patient died from the rupture of an aortic dissection on his way back to the ED the following day.
What Went Wrong?
In the case of the 35-year-old patient, the plaintiff alleged that our insured physician failed to provide a timely diagnosis of aortic aneurysm within two hours from admission, failed to diagnose a dissection by ordering a CT without contrast, and failed to accomplish a timely transfer. The plaintiff also alleged that the physician failed to diagnose a diastolic murmur that would have necessitated a transthoracic echo or CTA with contrast—tests that would have identified the dissection.
According to the defense, the ED physician diagnosed the aneurysm and appropriately made arrangements to transfer the patient to a hospital where corrective surgery could be performed. Experts in emergency medicine, cardiovascular surgery, and cardiology maintained that the patient was not ill-appearing, had normal vital signs, and had no family history of aortic aneurysms. Given these facts and the lab results, the experts determined that the insured’s work-up was appropriate.
In addition, our insured physician consulted with a cardiothoracic surgeon CTS and had a cardiologist examine the patient. Neither specialist wrote additional orders or provided recommendations for further testing or imaging. The physician had no control over the time it took to have the STAT CTA performed, nor did he have control over the speed of transfer to the accepting hospital. Lastly, a CTS expert testified that emergency surgery was not indicated, and the ED radiologist stated that he could not confirm presence of dissection with image ordered of CTA with no contrast.
The case of the 46-year-old patient was determined to be clear liability. The claimant alleged that his medical history, coupled with an equivocal chest x-ray, should have prompted our insured to perform further investigation with a CT scan. Our initial expert reviewer found that the decedent’s presentation was atypical for an aortic dissection, but the chest x-ray was clearly abnormal and warranted further imaging. The second reviewer determined that symptoms were not consistent with a dissection and the mediastinum was wide because the patient was short and obese. Out of an abundance of caution, defense requested a third review. In this physician’s opinion, the physician should have ruled out an aortic dissection with additional imaging, and he did not agree that the presentation was atypical.
Both cases settled before trial.
Risk Management Takeaways:
It’s essential that emergency medicine physicians follow accepted standard of care practices for ordering diagnostic testing when considering differential diagnoses. To help physicians, the American College of Radiology has established ACR Appropriateness Criteria for the diagnosis of suspected aortic dissection. When faced with a potential aortic dissection, our Risk Management team recommends the following:
- Physicians should complete a thorough patient assessment, including history, physical examination with electrocardiography, and laboratory and imaging studies. The doctor should consider further imaging studies when initial testing is abnormal, even with atypical presentations.
- Physicians should have a high clinical suspicion combined with diagnostic information to generate a pre-test probability to guide further diagnostic decisions.
- Consulting physicians should communicate all pertinent clinical findings and order additional diagnostic testing when warranted.
- When it’s necessary to transfer the patient to another facility, providers should contact the receiving physician as soon as possible to facilitate transfer before the patient’s condition deteriorates.
- During transport, patients with an aortic dissection should be monitored and accompanied by personnel capable of resuscitation. If a prolonged ground transport time is anticipated, physicians should consider air transport.
For further guidance on this issue, Medical Mutual members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.