Descending Thoracic Aortic Aneurysm: Case Presentation and Review

This section is reserved for commentaries and brief essays dealing with matters of interest to physicians. Material for consideration should not exceed five double-spaced typewritten pages. An honorarium of $75 is offered at the time of publication. Submissions should be addressed to: Editor, POSTGRADUATE MEDICINE, 4530 W 77th St, Minneapolis, MN 55435.     

A Cause of Sudden Death: Rupture of Thoracic Aortic Aneurysm

Sudden death occurred during antihypertcnsive therapy of a Stanford type A dissecting aortic aneurysw. Hemodynamic and electrocardiograpbic events were recorded including deterioration of ventricular fibrillation 4 minutes after rupture.     

Prospective Study of Accuracy and Outcome of Emergency Ultrasound for Abdominal Aortic Aneurysm over Two Years

Determination of the presence of an abdominal aortic aneurysm (AAA) is essential in the management of the symptomatic emergency department (ED) patient. OBJECTIVES: To identify whether emergency ultrasound of the abdominal aorta (EUS-AA) by emergency physicians could accurately determine the presence of AAA and guide ED disposition. METHODS: This was a prospective, observational study at an urban ED with more than 100,000 annual patient visits with consecutive patients enrolled over a two-year period. All patients suspected to have AAA underwent standard ED evaluation consisting of EUS-AA, followed by a confirmatory imaging study or laparotomy. AAA was defined as any measured diameter greater than 3 cm. Demographic data, results of confirmatory testing, and patient outcome were collected by retrospective review. RESULTS: A total of 125 patients had EUS-AA performed over a two-year period. The patient population had the following characteristics: average age 66 years, male 54%, hypertension 56%, coronary artery disease 39%, diabetes 22%, and peripheral vascular disease 14%. Confirmatory tests included radiology ultrasound, 28/125 (22%); abdominal computed tomography, 95/125 (76%); abdominal magnetic resonance imaging, 1/125 (1%); and laparotomy, 1/125 (1%). AAA was diagnosed in 29/125 (23%); of those, 27/29 patients had AAA on confirmatory testing. EUS-AA had 100% sensitivity (95% CI = 89.5 to 100), 98% specificity (95% CI = 92.8 to 99.8), 93% positive predictive value (27/29), and 100% negative predictive value (96/96). Admission rate for the study group overall was 70%. Immediate operative management was considered in 17 of 27 (63%) patients with AAA; ten patients were taken to the operating room. CONCLUSIONS: EUS-AA in a symptomatic population for AAA is sensitive and specific. These data suggest that the presence of AAA on EUS-AA should guide urgent consultation. Emergency physicians were able to exclude AAA regardless of disposition from the ED.     

食管超声心动图在胸主动脉瘤诊断中的应用价值──与CT、磁共振显像及血管造影对比研究

对照ＣＴ、磁共振显像（ＭＲＩ）及胸部大动脉Ｘ线血管造影（ＴＡＧ），分析１６例食管超声心动图结果，评估其诊断胸主动脉瘤的价值。１５例诊断正确，１例真性动脉瘤诊断为夹层动脉瘤ＤｅＢａｋｅｙⅢ型并血栓形成。同时检出主动脉瓣关闭不全６例、左室扩大５例。食管超声检出胸主动脉瘤的能力与ＣＴ、ＭＲＩ及ＴＡＧ相同，并能检出合并的主动脉瓣关闭不全、左室扩大及左室功能不全。     

Focused Cardiac Ultrasound

Cardiovascular and respiratory conditions in acute care require rapid, critical decision making, often with limited clinical information. Focused cardiac ultrasound (FOCUS) can aid in diagnosis by providing information that may not be evident from a patient's medical history, physical examination, and ancillary tests. Eight cases are presented in which FOCUS drastically altered the management of patient care, shortened the differential diagnosis, or allowed for the development of a definitive diagnosis. In 3 cases, diagnoses that were not initially suspected were identified by FOCUS. In the remaining cases, uncommon yet critical diagnoses were established at early stages along the patients' courses of care.     

彩色多普勒超声在急诊主动脉夹层动脉瘤中的应用

目的：评价彩色多普勒超声诊断急性主动脉夹层动脉瘤的临床价值。方法：对2000年8月～2002年2月间应用彩色多普勒超声技术诊断的6例急性主动脉夹层动脉瘤患者进行总结分析。结果：除1例超声诊断为Debakey Ⅰ型的患者在未能做其它检查前死亡外，另外5例Debakey Ⅲ乙型经血管造影证实，行支架型人工血管置入术治疗，1例Debakey Ⅲ乙型经增强CT扫描证实。结果：彩色多普勒超声检查对急性主动脉夹层动脉瘤的诊断及治疗方案选择具有重要的临床价值。     

主动脉窦瘤破裂的超声心动图诊断

目的评价主动脉窦瘤破裂(rupturedaorticsinusaneurysm,RASA)的超声心动图价值。方法复习文献,回顾性分析经手术证实的9例主动脉窦瘤的超声心动图特征。结果超声心动图可以准确显示窦瘤的形态、部位、破入心腔方向、血流动力学及并发症。结论超声心动图可于手术前及时、准确的诊断本病。     

彩色多普勒超声在主动脉夹层动脉瘤诊断中的价值

【目的】探讨彩色多普勒超声诊断主动脉夹层动脉瘤的临床价值。【方法】对采用彩色多普勒超声检查诊断的49例主动脉夹层动脉瘤患者进行回顾性总结分析。【结果】DebakeyⅠ型21例、DebakeyⅡ型11例、DebakeyⅢ型17例;术前正确诊断46例(93.88%),漏诊3例;经彩色多普勒超声诊断的主动脉夹层动脉瘤与CT、MRI、DSA检查诊断的符合率高。【结论】彩色多普勒超声检查对诊断主动脉夹层动脉瘤具有重要的临床价值。     

超声诊断胸主动脉瘤和夹层剥离

【目的】为评估多普勒超声检查诊断胸主动脉瘤或夹层剥离的价值。【方法】回顾分析经手术和心血管造影证实的超声资料较完整的胸主动瘤或夹层剥离２０例,结合图像、病理及临床进行探讨。【结果】其中弓、降部真性动脉瘤７例（３５％）,假性动脉瘤１例（５％）,升主动脉瘤７例（３５％）,夹层剥离５例（２５％）;超声误诊１例,诊断符合率９５％。【结论】升主动脉瘤多为Ｍａｒｆａｎ′ｓ综合征,弓、降部主动脉瘤均为动脉粥样硬化所致,在夹层剥离中彩超对判断真假腔、寻找破口有独特的价值     

彩色多普勒超声诊断主动脉夹层动脉瘤

目的 评价彩色多普勒超声诊断主动脉夹层动脉瘤的临床价值。方法对应用彩色多普勒超声诊断技术检查诊断的22例主动脉夹层动脉瘤患者进行总结分析。结果 经超声诊断的主动脉夹层动脉瘤与CT、MRI、DSA检查诊断的符合率分别为87．5％、83．3％、81．8％。检查方法、探测部位、所用切面影响诊断结果的准确性。结论 彩色多普勒超声检查对诊断主动脉夹层动脉瘤具有重要的临床价值。     

Common Iliac Artery Tortuosity Simulating Aortic Dissection on Focused Abdominal Ultrasound in the Emergency Department

Background

Bedside ultrasonography performed by the Emergency Physician is a safe procedure for evaluating patients with trauma, hypotension, chest or abdominal pain, and dyspnea of unknown origin.

Objectives

To present a case with apparent concordance between the patient's history, symptoms, signs, and ultrasound imaging, that lead to diagnostic error.

Case Report

A 74-year-old man was admitted to the hospital due to epigastric pain, radiating to the back. He reported previous detection of a small dilatation in the ascending aorta. On physical examination, the heart rate was 120 beats/min and the blood pressure was 90/60 mm Hg. These facts suggested the possibility of an aortic dissection; therefore, a bedside emergency ultrasound examination was performed. The first part of the examination focused on the ascending aorta, but the results were not significant. Then, an abdominal evaluation was performed that revealed an ovular and pulsatile anechoic mass in the infrarenal tract, with an echoic wall and an endoluminal flap. A computed tomography scan of the aorta was ordered, and it showed a regular aorta in the entire tract, with an abnormal tortuosity of iliac arteries as the basis of the false-positive ultrasound.

Conclusions

The use of ultrasound in emergency settings has improved the clinical evaluation of critical patients by Emergency Physicians, but the possibility of a false-positive diagnostic error always should be considered.     

Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

Objectives: The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high‐risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population. Methods: A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June–August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers’ opinions) and the prevalence of AAA (aortic diameter of ≥3.0 cm) in the study sample. Results: During the 12‐week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening. Conclusions: Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high‐risk patients.     

经胸超声心动图诊断升主动脉瘤

目的探讨应用TTE对升主动脉瘤的诊断价值.方法对16例经CT、MRI及手术证实为升主动脉瘤的声像图及CDFI进行了分析,并结合文献总结了其CDFI的诊断与鉴别诊断.结果升主动脉瘤分为真性动脉瘤、假性动脉瘤及夹层动脉瘤三种类型.真性10例,假性1例,夹层主动脉瘤5例.真性主动脉瘤管腔局部扩张,当升主动脉扩张＞50mm时可诊断为动脉瘤.夹层主动脉瘤病变动脉内可见撕裂的动脉内膜.假性动脉瘤是由动脉壁部分破裂,血液溢出血管外形成的包裹性血肿,而非真性动脉扩张.结论TTE可对绝大多数的升主动脉瘤做出明确诊断.可作为随访观察升主动脉扩张及筛检升主动脉瘤的首选方法.     

急性主动脉夹层动脉瘤早期诊断问题──附21例病例报告

急性主动脉夹层动脉瘤发病急骤，临床表现复杂，相当多的病例易漏诊、误诊，本文分析21例急性主动脉夹层动脉瘤临床特征和诊断情况，根据经治经验、提出急诊早期对本症的诊断线索，并对各种诊断方法作了初步评价。     

Rupture of an Ascending and Descending Thoracic Aortic Aneurysm Causing Tension Hemothorax: A Case Report

Background: A ruptured thoracic aortic aneurysm is a life-threatening condition and can lead to a tension hemothorax. Objectives: To describe the presentation and management of a case of a tension hemothorax. Case Report: An 84-year-old woman presented in respiratory distress and was found to have a tension hemothorax. The cause was the rupture of an ascending and descending thoracic aortic aneurysm. She was managed with intubation, mechanical ventilation, and chest tube placement with stabilization. Definitive operative repair was deferred due to the patient's comorbidities and wishes of the family. Conclusions/Summary: A tension hemothorax can result from an ascending and descending thoracic aneurysm, as this case describes. Emergent therapy is necessary as this is a life-threatening condition.     

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax

Objective

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

Methods

We conducted a retrospective institutional review board–approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

Results

A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58–97), specificity of 100% (95% CI 99–100), positive predictive value of 81% (95% CI 54%–95%), and negative predictive value of 100% (95% CI 99%–100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%–78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

Conclusions

Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.     

腹及胸腹主动脉瘤围手术期的护理探讨

报告 198 6年～ 1998年间收治的腹及胸腹主动脉瘤 72例 ,其中胸腹主动脉瘤 (ThoracoabdominalAoticA neurysm ,TAAA) 8例 ,腹主动脉瘤 (AbdominalAorticAneurysm ,AAA) 6 4例。 6 5例行手术治疗 ,1例髂总动脉埋泵 ,6例未手术。详细讨论了腹及胸腹主动脉瘤围手术期的护理在成功治疗该血管疾病中的重要性