A Case Report of Prehospital Point-Of-Care Ultrasound in Acute Aortic Dissection: Reinforcing the Out-of-Hospital Chain of Survival.

Abstract

This case report highlights the importance of point-of-care ultrasound (POCUS) in the prehospital setting when cute aortic dissection is suspected. At 2:09 p.m. the local emergency medical services (EMS) received a call from a small town in Lombardy, Italy, reporting that a 54-years-old man had collapsed while lifting weights in a fitness club. Response teams found him lying on the floor, fully responsive and very pale; he was a lean and healthy man, with no allergies, no home therapy and no significant past medical history. He had had a transient facial paralysis and complained of dizziness and mild chest discomfort. During physical examination he became suddenly hypotensive (60/30 mmHg). The electrocardiogram showed a sinus rhythm, 80 beats per minute (bpm) and unaltered T wave and ST segment. The POCUS showed a dilated aortic root with intimal flap and small pericardial effusion. A diagnosis of Type A acute aortic dissection was made on the spot. The EMS dispatch center identified the closest hospital with available cardiothoracic surgery and provided a full report of the patient's condition, diagnosis and initial treatment. At 3:10 pm, the patient entered the emergency room and a rapid transthoracic ultrasound confirming the diagnosis was performed in the presence of the cardiac anesthetist and cardiothoracic surgeon. The patient was agitated, tachycardic (110 bpm) and hypotensive (50/30 mmHg). Upon stabilization with intravenous norepinephrine and fluids, a computed tomographic angiogram was performed demonstrating a Stanford Type A aortic dissection with intimal flap starting from the bulb/valvular plane and extending to the origin of supra-aortic trunks down to the left common iliac artery. At 4.00 p.m. the patient was ready for surgery; he underwent successful ascending aorta replacement with a regular postoperative course and no signs of neurological damage. On post-operative day eight he was referred to an inpatient cardiac rehabilitation facility and later discharged home. At prehospital level, POCUS is feasible and may provide key diagnostic findings in some threatening medical (non-trauma-related) conditions that are normally diagnosticated only once the patient has reached the hospital. In addition, this report highlights a perfect interaction between out-of-hospital medical personnel, dispatch center and in-hospital multidisciplinary health staff.