Authors: Tom Bannister / Codes: CC7, CP1, SLO2, SLO3, VC2 / Published: 17/06/2024

Scope / Reason for development

Diagnosis of thoracic aortic dissection in adult patients attending the emergency department. The guideline focuses on diagnosis rather than management.

The diagnosis of thoracic aortic dissection (TAD) is often difficult to establish in emergency department (ED) patients attending with chest pain. Key to making the diagnosis is the awareness amongst emergency physicians (EPs) of the need to consider the diagnosis in patients presenting with chest pain. EPs should also have an awareness that TAD can present subtly or in young patients and that their pain may have migrated or dissipated by the time they are seen. Surveillance data suggests that opportunities to diagnose cases of TAD are being missed in the ED, often with catastrophic consequences. This guideline seeks to provide a consensus opinion with regards to which patients should be considered for CT scanning (the diagnostic modality of choice) whilst accepting that this is still an area of considerable controversy and concern.

Summary of Recommendations

  1. All clinicians working in the emergency department should be made aware of the difficulties in excluding the diagnosis of TAD and the need to be aware of local policies and resources to assist in this as part of their induction.
  2. Each emergency department must have agreed protocols between themselves and their radiology department regarding requests for CT Aortagrams in cases of suspected thoracic aortic dissection.
  3. Thoracic aortic dissection is a time critical emergency and provision must be available for the ED to rapidly access CT Aortagrams throughout the whole 24hr period.
  4. If the ED suspects a patient has a TAD it is the role of the ED to request the scan and act on the result. This responsibility should not be passed onto another clinical team.
  5. All emergency departments should have a local protocol or pathway detailing the actions to be taken once a diagnosis of TAD has been made. This should include details of blood pressure management and local urgent referral pathways to specialist surgical centres, where appropriate.

Ensure that you read the full Diagnosis of Thoracic Aortic Dissection in the Emergency Department Guideline

Key information

For patients presenting to the emergency department with chest pain, a CT Aortogram (CTA) should be requested if any of the high risk features below are present or in the case of more than one high risk feature from different boxes a CTA whole aorta UNLESS another cause of the chest pain is clearly identified and evidenced eg. acute myocardial infarction, pneumothorax, pulmonary embolus etc.

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