期刊名称：Journal of Education and Teaching in Emergency Medicine
印刷版ISSN：2474-1949
出版年度：2018
卷号：3
期号：4
页码：32-34
DOI：10.21980/J84H00
出版社：University of California Press
摘要：History of present illness: A 68-year-old female presented with back pain described as burning in her mid to
upper back radiating to her chest with nausea and vomiting for several hours, which progressed to active
hematemesis. Her vitals were significant for hypertension (160/95) and bradycardia (57). Her exam was
notable for diminished breath sounds in the bilateral bases with rhonchi in the left lung base, and epigastric
tenderness without rebound or guarding. A portable X-ray followed by a computed tomography (CT)
angiogram of the chest and abdomen were ordered. Upon return from CT, the patient developed
hypotension, worsening bradycardia, and altered mentation.
Significant findings: The patient’s chest X-ray revealed a prominent mediastinum and opacification in the left
middle and lower lung fields. The CT showed an aortic aneurysm extending from the thorax to the abdomen
with rupture near T7 (blue arrow). It also showed periaortic hemorrhage with active extravasation (green
arrow) likely secondary to a penetrating ulcer and bilateral pulmonary opacities concerning for hemothorax
(pink arrow).
Discussion: Thoracic aortic aneurysm (TAA) is a progressive and potentially deadly disease with a poor
prognosis when left untreated.1 Most TAAs are asymptomatic and may be detected incidentally on imaging.
Although presentation can vary, chest or back pain might be the first presenting symptom and can represent
rapid expansion, acute dissection, or rupture.2 In the acute setting, chest X-ray might be the first imaging
study performed during the initial evaluation of a patient with symptoms that suggest a potential for aortic
disease. Predictive sensitivity of a widened mediastinum or abnormal aortic contour can be around 64% and
71% respectively, but the sensitivity of CXR is not adequate to definitively rule out acute aortic disease.3 CT
with contrast remains the imaging study of choice for diagnosis of acute thoracic aortic disease; it can be
nearly 100% sensitive and can also demonstrate the presence of a dissection flap or rupture.3
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Overall mortality for ruptured TAA is 97%-100%.4 While mortality is also high for repair of symptomatic TAA,
repair is recommended for all symptomatic TAA (ruptured, associated with dissection, or causing pain).2
However, surgery may not be indicated based on patient comorbidities, or clinical picture. Preemptive repair
of asymptomatic TAA can eliminate the risk of rupture, which is primarily predicted by size.5 Overall mortality
for elective repairis 4.5% (4.6% for open repair and 3.6% for endovascularrepair).6 Current guidelinessuggest
surgical intervention when the risk of rupture-related complications exceed the risk of surgery-related
complications, which is generally around a size of 5.5 cm. However, it is also dependent on the presence of
genetic risk factors for dissection and rupture, exact location, and rate of aneurysm expansion.3
In this case, cardiothoracic surgery determined that surgery would not confer any increased chance of
survival based on the patient’s clinical condition, the size and location of the rupture, and the growing
periaortic hemorrhage. The family decided to provide comfort measures only and the patient expired
approximately one hour after presentation to the emergency department.
