Tearing Interscapular Pain With a Widened Mediastinum

Framing. Abrupt, maximal-at-onset tearing interscapular pain in a chronically hypertensive man, plus a widened mediastinum, puts acute aortic dissection first, with ACS and PE behind it. The exam does not have to show a pulse deficit for dissection to be present.

Do now

• Two large-bore IVs, arterial line if you can place one quickly, type and screen, Foley for hourly urine output.
• Analgesia with IV fentanyl 25-50 mcg titrated. Pain drives catecholamines, which drive shear stress (dP/dt) across the intimal tear.
• Rate and pressure control before the scanner, not after (see next question).
• CT angiography of chest, abdomen, and pelvis. The whole aorta must be imaged because extent dictates operative planning and malperfusion risk.
• Call the cardiothoracic surgeon and the transfer service in parallel with imaging, not afterward.

Deliberately do not

• No aspirin, heparin, clopidogrel, or fibrinolytic. If this is a dissection, lysis risks fatal rupture or tamponade. The 1 mm lateral ST depression is not a STEMI trigger, and even a dissection that dissects into a coronary ostium and produces ST elevation belongs in an operating room, not a cath lab or a lytic protocol.
• No pure vasodilator as the first drug (see next question).
• Do not let a pending or normal troponin, or a low-risk chest pain score, redirect you; none of these excludes dissection.
• Do not use bedside transthoracic echo as a rule-out. It misses a meaningful share of dissections, and a negative study does not cancel the CTA.

Targets. Heart rate 60/min or less and systolic pressure 100-120 mmHg (or the lowest pressure that keeps mentation, urine output, and perfusion intact; a MAP around 60-70 mmHg is a reasonable floor). The goal is to reduce the rate of pressure rise in the aorta, not just the peak pressure.

Sequence: rate first, then pressure.

1. Esmolol 0.5 mg/kg IV bolus over 1 minute, then 50 mcg/kg/min, titrating by 50 mcg/kg/min to a maximum of about 200-300 mcg/kg/min. Preferred because of its seconds-long half-life if the patient becomes hypotensive or develops tamponade physiology. Alternative: labetalol 10-20 mg IV every 5-10 minutes or an infusion at 0.5-2 mg/min.
2. Then add a vasodilator if systolic pressure is still above target: nicardipine 5 mg/h, titrated by 2.5 mg/h every 5-15 minutes to a maximum of 15 mg/h.

Why this order. A vasodilator given alone produces reflex tachycardia and a steeper dP/dt, which increases shear force on the tear and can extend the dissection. Blocking first prevents that reflex. Nitroprusside is effective but carries cyanide risk and is harder to titrate; nicardipine or clevidipine are easier in transport. If acute aortic regurgitation or tamponade is suspected, esmolol's titrability matters more than potency. Reassess blood pressure in both arms and watch for hypotension, which signals tamponade or rupture and changes the plan from pressure control to guarded, small-volume resuscitation and immediate surgical transfer.

Disposition. Type A dissection is a surgical emergency. Confirm acceptance with cardiothoracic surgery, transfer by air (35 minutes) rather than ground (90 minutes), and send the images ahead. Continue the esmolol and nicardipine infusions en route with a transport-capable pump.

While waiting

• Continue analgesia; keep heart rate and pressure at target.
• No antiplatelets or anticoagulants. Do not place central lines or invasive lines that are not truly needed, and avoid femoral arterial puncture if the dissection extends to the iliac vessels.
• Screen for malperfusion: recheck pulses and blood pressure in both arms, mental status, urine output, abdominal exam, and a focused neuro exam. New deficits, oliguria, or limb ischemia change urgency and may require the surgeon to consider a different operative approach.
• Keep the patient NPO, crossmatched for blood, and have a massive transfusion plan in place.
• Do not induce hypotension with a fluid bolus reflexively. If pressure falls, think tamponade, rupture, or myocardial ischemia, and give small aliquots of fluid while getting to the operating room. Intubation can precipitate collapse in tamponade physiology, so preload and hemodynamics need to be optimized before any sedation for airway.
• Speak to the family about the diagnosis, the operative mortality, and the need for lifelong blood pressure control and surveillance imaging.

Trap to avoid. A type B dissection, by contrast, is usually managed medically unless there is malperfusion, rapid expansion, or rupture. Getting the type right before committing to transfer is essential.