A 27-year-old woman is brought to the emergency department due to a 4-hour history of chest pain that is localized to the middle of the chest and the upper sternal area. She describes it as "intense." The patient has never before experienced a similar pain. She also describes some nausea and a mild occipital headache. She has had no vomiting, abdominal pain, or shortness of breath. A friend who accompanies her to the emergency department says that they attended a party and the patient smoked crack cocaine shortly prior to her episode of chest pain. She did not consume alcohol. The patient has a history of intravenous drug use. She was treated with antibiotics for upper extremity cellulitis 6 months ago. There is no family history of premature coronary artery disease. The patient does not take any medications and has no known drug allergies. On initial evaluation, temperature is 37.8 C (100 F), blood pressure is 204/102 mm Hg on the right arm and 210/104 mm Hg on the left arm, pulse is 102/min and regular, and respirations are 18/min. Oxygen saturation is 99% on room air. The patient appears thin, anxious, and agitated. Heart sounds are normal and no murmurs are heard. Lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Lower extremity pulses are full and symmetric. There is no peripheral edema. ECG shows sinus tachycardia but is otherwise unremarkable. Portable chest x-ray reveals clear lung fields. Finger-stick blood glucose level is 98 mg/dL. After 2 hours in the emergency department, the patient has weakness in her right arm. Her chest pain is somewhat better, but she still has pain at the middle and upper part of the sternum. She has been treated with lorazepam, morphine, and nitroglycerin infusion. Blood pressure is 133/80 mm Hg and heart rate is 88/min and regular. Neurologic examination shows mild muscle weakness affecting the right upper and lower extremities. Speech is normal. Repeat ECG shows normal sinus rhythm with no significant abnormalities. Laboratory results are as follows:
Immediate noncontrast CT scan of the head reveals no evidence of bleeding. Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman is brought to the emergency department due to a 4-hour history of chest pain that is localized to the middle of the chest and the upper sternal area.  She describes it as "intense."  The patient has never before experienced a similar pain.  She also describes some nausea and a mild occipital headache.  She has had no vomiting, abdominal pain, or shortness of breath.  A friend who accompanies her to the emergency department says that they attended a party and the patient smoked crack cocaine shortly prior to her episode of chest pain.  She did not consume alcohol.  The patient has a history of intravenous drug use.  She was treated with antibiotics for upper extremity cellulitis 6 months ago.  There is no family history of premature coronary artery disease.  The patient does not take any medications and has no known drug allergies.  On initial evaluation, temperature is 37.8 C (100 F), blood pressure is 204/102 mm Hg on the right arm and 210/104 mm Hg on the left arm, pulse is 102/min and regular, and respirations are 18/min.  Oxygen saturation is 99% on room air.  The patient appears thin, anxious, and agitated.  Heart sounds are normal and no murmurs are heard.  Lungs are clear to auscultation bilaterally.  The abdomen is soft and nontender.  Lower extremity pulses are full and symmetric.  There is no peripheral edema.  ECG shows sinus tachycardia but is otherwise unremarkable.  Portable chest x-ray reveals clear lung fields.  Finger-stick blood glucose level is 98 mg/dL. After 2 hours in the emergency department, the patient has weakness in her right arm.  Her chest pain is somewhat better, but she still has pain at the middle and upper part of the sternum.  She has been treated with lorazepam, morphine, and nitroglycerin infusion.  Blood pressure is 133/80 mm Hg and heart rate is 88/min and regular.  Neurologic examination shows mild muscle weakness affecting the right upper and lower extremities.  Speech is normal.  Repeat ECG shows normal sinus rhythm with no significant abnormalities. Laboratory results are as follows:
 Immediate noncontrast CT scan of the head reveals no evidence of bleeding.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with recent cocaine ingestion has persistent chest pain despite adequately controlled heart rate and blood pressure and no evidence of ischemia on ECG. The chest pain in combination with new neurologic findings of right-sided weakness is highly suspicious for acute dissection of the ascending aorta. Severe hypertension due to cocaine ingestion is one of the most common causes of acute aortic dissection in young patients. In dissections involving the ascending aorta (type A dissections), patients typically have sharp anterior chest pain (back pain is more common in type B dissections). Focal neurologic deficits can occur; this patient's right-sided weakness is suggestive of carotid artery involvement (eg, obstruction by intimal flap, extension of dissection into carotids) leading to cerebral ischemia. acute dissection of the ascending aorta Acute dissection of the ascending aorta is a surgical emergency; rapid diagnosis and treatment are critical to reduce morbidity and mortality. The diagnosis is confirmed by noninvasive imaging, including CT angiography, magnetic resonance angiography, or transesophageal echocardiography. (Choice A) Carotid artery ultrasound is typically used to evaluate for atherosclerotic carotid artery stenosis. Significant atherosclerotic disease is extremely unlikely in this young woman. (Choice C) Fibrinolysis with intravenous alteplase is indicated within 4.5 hours of symptom onset of thrombotic ischemic stroke. Although acute cocaine ingestion increases the risk for stroke due to arterial vasospasm and activation of clot formation, thrombotic stroke does not explain the persistence of chest pain. This patient's focal weakness is more likely explained by acute aortic dissection, for which fibrinolysis is contraindicated. (Choice D) Phentolamine (alpha receptor antagonist) is not indicated as this patient's blood pressure is under control. (Choice E) Anticoagulation (eg, low-molecular-weight heparin) is indicated for the treatment of acute coronary syndrome. However, this patient's normal ECG and normal troponin levels make acute coronary syndrome unlikely. Anticoagulation is contraindicated in the setting of acute aortic dissection. Educational objective: The presence of persistent chest pain and neurologic symptoms in a patient with recent cocaine use should raise suspicion for acute dissection of the ascending aorta. Rapid diagnosis is essential and can be made by CT angiography of the chest. References: Acute aortic dissection related to crack cocaine. (http://www.ncbi.nlm.nih.gov/pubmed/11927528) Cocaine-related aortic dissection: lessons from the International Registry of Acute Aortic Dissection. (http://www.ncbi.nlm.nih.gov/pubmed/24835037)

A 27-Year-Old Woman Is Brought to the Emergency Department Due