Delayed Diagnosis of Aortic Dissection Led to Cardiac Tamponade

Allegation

Failure to timely diagnose and treat aortic dissection resulting in death

Case Details

EMS was dispatched to a bowling alley for a 69 YOM with a syncopal episode who struck his face on a table. He was found unresponsive on the floor, his respirations gasping and irregular. A large facial hematoma and laceration were evident. VS were stable with initial Glasgow Coma Scale (GCS) of 7/15 improving to 15/15 in 10 minutes. Paramedics noted initial left side flaccidity improving to weak movement and slurred speech. The patient eventually became more alert. An EKG was not done due to the patient’s combativeness.

The patient arrived alert and oriented x 3 to the ED in less than 30 minutes where the stroke protocol was initiated, including head CT without contrast. TPA was not ordered. NIH Stroke Scale was recorded as 2/34. Cardiac and neurological examinations were negative. CXR and CT of head and c-spine were ordered. A history of HTN was noted, with B/P of 99/76 and pulse 116. Pain 4-7/10. An EKG noted sinus tachycardia and PAC’s with borderline prolonged QT interval.

Laboratory testing revealed elevated WBC 14 (4.5-11), glucose 178 (70-99), BUN/Creatinine 27/1.37, and BAC of 0.057. Cardiac enzymes and Troponin were normal. The CXR found mild tortuosity of the aorta similar to prior x-rays, and no definite plain radiographic evidence of acute cardiopulmonary abnormality. A CT of his spine found no acute fracture or dislocation. The head CT was negative except for soft tissue swelling and hematoma overlying the right maxilla. Treatment included 500cc NS bolus for a B/P of 88/56. Zofran and Ativan IV, 1L NS bolus for decreased B/P of 71/49, and 02 2L NC.

The patient was admitted to IMCU under the defendant internal medicine (IM) physician’s care, with dx of TIA, syncope, alcohol intoxication, blunt head trauma, facial contusion, vomiting, and hypotension. CP 2/10 with deep breath. B/P improved to 113/76, pulse 78. A consulting neurologist stated no stroke protocol. A cardiology consult was ordered. Lisinopril was held due to normal to low blood pressure.

The patient’s condition and vital signs remained stable through the night and the next day. A repeat NIH Stroke Scale was 0. A second CXR was unremarkable. The cardiologist’s findings included no previous cardiac history, dyspnea, pedal edema, or palpitations. Impression was syncopal episode, suspect orthostatic hypotension likely related to Lisinopril. Discharge was ordered with office follow-up.

The defendant IM physician evaluated the patient in the late afternoon and was awaiting a neurology consult. His examination was WNL, no headaches, lightheadedness, chest pain, dyspnea, abdominal pain, nausea, or vomiting. Treatment included PT/OT evaluation, neurology evaluation and treatment plan, and await the patient’s progress and course during hospitalization.

The patient became more anxious about discharge as evening came. The neurologist was called regarding the consult, and upon reviewing diagnostic test results through the EMR, stated the patient could be discharged with follow-up in one to two weeks. VS remained WNL and the patient denied pain. He was ambulatory with steady gait, and without dizziness or lightheadedness, shortness of breath or chest pain.

The defendant IM physician was paged and called by nursing staff several times over the course of one hour, at which time the on-call physician for cardiology and the back-up for the defendant IM physician returned the call to the nurse. The physician was informed of the cardiologist and neurologist reviews and orders for discharge. The physician ordered discharge with a follow-up plan and the patient was discharged minutes later.

Less than 30 minutes after discharge, EMS was called to the parking lot of a church where the spouse had stopped due to the husband’s complaint of sudden onset head pain and vomiting. EMS found him on the ground and not breathing. CPR and ALS protocol was initiated, and the patient was transferred to the ED. ALS protocol continued in the ED without success and the patient was declared dead 20 minutes after arrival. The wife requested an autopsy which found the cause of death was cardiac tamponade due to pericardial effusion due to acute aortic dissection.

Expert Testimony

The Medical Review Panel issued mixed opinions, but the majority found the evidence supported the defendant’s failure to comply with the appropriate standard of care. However, they deferred as to causation in resultant damages. The Medical Review Panel was critical of the communication failures.

Plaintiff expert criticisms included the lack of diagnostic testing, specifically an echocardiogram and chest CT, and more in-depth assessment of presenting symptoms.

Defense experts were supportive of the care provided given the patient did not present with typical symptoms of aortic dissection, was not experiencing severe pain, and diagnostic testing did not show evidence of cardiopulmonary problems. The hospital course was stable, and the patient was ambulatory without pain prior to discharge.

Resolution

The patient’s estate filed suit for failure to timely diagnose and treat aortic dissection resulting in death. Evidence did not support the complaint that defendant failed to meet applicable standard of care, resulting in a verdict in favor of the defendant IM physician.

Risk Reduction Strategies

Risk Management considerations include ensuring that there is clear and timely communication among the attending and consulting physicians, clear communication and direction to hospital clinical staff caring for the patient, and documentation of the decision-making in the treatment plan.

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