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Chest Pain in a Patient With Hypertensive Emergency


Case Study

A rapid response event was initiated by the bedside nurse for new-onset, severe chest pain. Upon prompt arrival of the rapid response team, it was found that the patient was a 47-year-old male with a known history of insulin-dependent diabetes mellitus, hypertension, and substance abuse. He was admitted a few hours earlier for altered mental status and bizarre behavior, and a urine toxicology screen was found to be positive for cocaine and methamphetamines. The patient had developed acute onset, sub-sternal, 10/10 chest pain 10 min before the rapid response event was initiated. The pain was stabbing and radiating to his back. He was nauseous but denied any other symptoms.

Vital Signs

  • Temperature: 100°F, axillary

  • Blood pressure: 240/135 mmHg

  • Pulse: 145 beats per min (bpm) – narrow complex tachycardia on telemetry

  • Respiratory rate: 32 breaths per min

  • Pulse oximetry: 97% oxygen saturation on room air

Focused Physical Exam

The patient was a middle-aged male sitting up in bed in severe distress. His respiratory exam showed tachypnea and labored breathing, but the lungs were clear to auscultation. A cardiac exam showed tachycardia with a regular rhythm; no murmurs were identified. No edema was present. The abdominal exam was benign.

Interventions

A cardiac monitor was attached. A stat electrocardiogram (EKG) was obtained, which showed sinus tachycardia; no ST changes related to acute ischemia were present. The patient was given 2 mg IV morphine for pain. He was also given 10 mg IV labetalol for elevated blood pressure, and a stat bedside chest X-ray was obtained. Chest X-ray showed a widened mediastinum indicating aortic dissection. The patient was started on esmolol infusion, and a stat computed tomography (CT) angiogram of chest and abdomen per dissection protocol was ordered. Imaging was consistent with dissection of the descending thoracic aorta ( Fig. 3.1 ). An emergent consult was called to thoracic surgery, and the patient was transferred to the intensive care unit for further management.

Fig. 3.1, CT angiogram of the chest showing an intimal tear in the descending thoracic aorta and formation of false lumen separated from the true lumen by an intimal flap.

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