53 Year Old Male: Severe Leg Pain–Conclusion

This is the conclusion to 53 year old male: Severe leg pain. You may wish to review the case.

Before we begin, my apologies for the delay in posting this conclusion. I live in coastal NY, and we got hammered by Hurricane Sandy. It has taken me a little time to get all caught up.

This is not an easy case. Our patient's chief complaint is of sudden onset of severe leg pain, and chest pain. Also notable is the measured hypertension.

Here is another look at the second 12 lead, which showed the following changes from the first:

There is sinus tachycardia, at a rate slightly above 100 bpm. There is physiologic left axis deviation. There are no signs of chamber enlargement, and the QRS is normal width. There is slight ST elevations in I and aVL, with ST depressions in the inferior leads, as well as V2 and V3.

At this point, our list of DDX should probably include:

  • DVT
  • Possible aortic dissection
  • STEMI

The patient's complaint sounds like it could be DVT, as many readers pointed out. We might expect to see swelling and redness as well, and this was not noted by the EMS crew. These signs and symptoms are not sensitive, however, as about 50% of people with DVTs will not have them. 

The patient is hypertensive, with chest pain, which led some of you to suggest an aortic dissection. Usually there is sudden onset of maximal chest pain, 10/10, with a "ripping" or "tearing" sensation. We do not have those typical signs and symptoms here by history. 

The patient does have ischemic signs on the 12 lead, consistent with lateral STEMI, but the patient's main complaint seems to be leg pain, not the chest pain.

 

So, how do we manage this patient? 

 

For starters, I think this is a tough patient to figure out. We have three good possibilities on our list of DDX, and two of them are immediately life threatening. 

I look at it this way, and of course it is with the benefit of hindsight. There seems to be more going on here than DVT, based on the patient's presentation, chest pain and 12 lead ECG. 

STEMI seems to be a reasonable assumption based on the 12 lead, but I would be thinking that as an atypical presentation (leg pain), this would almost be off the charts. It just doesn't seem like STEMI.

We also know that other conditions can cause ischemic changes on the ECG, and a dissecting aorta is one of them. 

Of course, O2 and IV access are indicated. NTG is a good possibility because it would be beneficial in either scenario. 

With that in mind, I would at least make sure we are transporting the patient to a hospital that can handle both STEMI and surgery for dissecting aorta. 

If a dissection progresses in a retrograde direction towards the aortic root, an acute total or partial occlusion of one of the main coronary arteries can occur. Usually, it is the RCA that is involved, but unusually, it can involve the left main. In the ED, heart rate and blood pressure will be controlled until surgery is performed. You can read more about this phenomenon here

As you have probably surmised by now, this was the fate of our patient. Once in the ED, a CT scan revealed a dissection of the ascending aorta. This dissection caused a partial occlusion of the LMCA. The patient underwent extensive surgery to repair the aorta. He was expected to make a strong recovery. 

We hope you enjoyed this unusual case! As always, comments are encouraged!

 

 

5 Comments

  • nate says:

    did the pt have extension of the dissection down to the illiac arteries?  did the thoracic dissection explain the leg pain?

  • CJ Ewell says:

    Overlooked in the differntial is an arterial embolus in the leg, possibly a widespread coagulation disorder that could also cause cardiac artery involvement. I'm with you, go to the best equipped place you can.

  • roger m says:

    with disections you can have plaque rupture that will migrate to the feet at a later date turning them black and will have to be watched closely

  • Dr.boris says:

    Have you ever thought of using a blood flow stimulation kit? I recommended them for most of my patients dealing with this. Check it out. [url]http://www.kingbrand.com/Leg_Injury_Treatment.php?REF=Boris1011[url]

  • tramadol says:

    You can certainly see your enthusiasm in the article you write.
    The world hopes for even more passionate writers like you who are not afraid to mention how they believe.
    At all times follow your heart.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Ruud Valkenborg
Snapshot Case: What Happened?
Beautyfull R on T with a unsynchronised ECV. :-)
2015-05-27 07:38:19
george
Snapshot Case: What Happened?
why cardiovert urgently in this case? The first strip shows a "well controlled" heart rate. Cardioversion provoked torsade de points due to unsync administration....... Unnecessary risk taken......when amiodarone or flecainide would do the job "quietly".....
2015-05-27 06:46:53
Joe
Snapshot Case: What Happened?
Pt has some wicked bi-phasic T-waves s/p defibrillation...
2015-05-27 04:01:32
Greg
Snapshot Case: What Happened?
Unsynced cardioversion! I mirror the comments above wondering why this patient even required cardioversion for this afib as the rate doesn't seem particularly sinister. And after 4 shocks maybe consider that the afib might not respond at all and focus on other treatment avenues.
2015-05-27 02:56:05
Sam
Snapshot Case: What Happened?
The patient appears to have been unintentionally cardioverted during the relative refractory period, which can send the heart into v-fib. The first attempt looks to be 50J, under the 120J usually recommended for rapid a-fib, and did not work. Before the second attempt, it appears that there is no longer capture and the patient was…
2015-05-26 23:51:11

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