Aortic dissection is a life-threatening medical condition where the inner layer of the aorta tears, allowing blood to flow between the layers of the aortic wall. In the emergency room, aortic dissection remains a diagnosis that is often elusive because of its varied presentations. Additionally, it is the diagnosis that if missed, is catastrophic for patients with a high rate of death and disability.  After practicing for 20 years, I have seen many different variations of aortic dissection, below are the top reasons that the diagnosis can be missed, leading to malpractice claims.

Misdiagnosis or Delayed Diagnosis

Aortic dissection was traditionally referred to as a “chest pain AND syndrome” as it often presents with chest pain and an additional, seemingly unrelated complaint. The nature of the complaint depends on where the dissection has propagated and what additional end-organ is affected:  For example:

  • Chest pain AND left-sided weakness (dissection affected vasculature leading to stroke)
  • Chest pain and back pain (dissection has affected spinal arteries)
  • Chest pain and abdominal pain (dissection has affected gastric arteries)

Unfortunately, this overlap can lead to misdiagnosis or delayed diagnosis, the most common malpractice causes in aortic dissection cases. Even worse, it may lead to treatments that are contraindicated for dissection. For example, administering thrombolytics for an aortic dissection that mimics a stroke can be fatal to a patient. Failure to recognize the importance of chest pain and unrelated complaints as a potential dissection, and keep aortic dissection on the differential diagnosis is the top reason the diagnosis is missed.

Delays in Imaging

Given the critical nature of aortic dissection, timely diagnosis is essential. However, if dissection is not immediately on the differential diagnosis,  tests that will confirm the diagnosis can be delayed several hours or more, worsening the prognosis. For example, patients who present with stroke-like symptoms may have scans of the brain performed, neurologic consultation, and other tests all delaying the diagnosis of dissection for several hours or more.   A 2017 case that settled for $4 Million involved a 51-year-old woman who suffered permanent paralysis after a delayed diagnosis of aortic dissection. Despite presenting with symptoms consistent with this condition, a chest CT/CTA was not initially ordered. When the dissection was finally detected, the woman had developed permanent paralysis in her lower extremities. 

Inadequate Medical History and Physical Examination

Taking a thorough medical history and conducting a detailed physical examination are essential steps in identifying patients at risk for aortic dissection. A common issue seen in documentation is not corroborating the patient history given to EMS personnel or to a triage nurse.  For example, patients may complaint of severe, sudden chest pain that is maximal in intensity to EMS personnel, but if this same history is not elicited by the medical providers -as the patient may be in more distress or their clinical status is changed – then aortic dissection may not be on the differential diagnosis of the provider. Providers must corroborate patient history with triage and pre-hospital notes to ensure the patient’s complaints are consistent.  Additionally, pertinent risk factors for dissection are not always elicited:  Risk factors such as connective tissue disorders (Marfan syndrome),  a family history of aortic disease, or a history of cocaine use are all known to be risk factors for aortic dissection and must be part of the routine history of patients where the diagnosis is a possibility.

Improper Treatment Decisions

Even when aortic dissection is diagnosed correctly, improper treatment decisions can lead to malpractice claims. The treatment of aortic dissection depends on the location and severity of the dissection, and it typically requires emergency surgery or aggressive medical management to stabilize the patient. Errors in judgment, such as deciding against surgery when it is warranted or inadequately managing blood pressure, can lead to poor outcomes.    Patients with acute aortic dissection typically require two major early interventions from the ER:  eary, aggressive blood pressure control to prevent the propagation of the dissection, and early surgical consult to decide on a patient’s ultimate disposition. A lack of urgency or delay with either of these treatment decisions can lead to worsening of the dissection leading to permanent end-organ damage.

Conclusion

Aortic dissection is one of the most catastrophic presentations that present to the emergency department. The complexity of the condition, combined with its potential to present with nonspecific symptoms, increases the risk of medical errors and often makes the diagnosis difficult. Misdiagnosis, failure to order appropriate tests, inadequate examination, and improper treatment, are the top reasons for medical malpractice in aortic dissection cases. To reduce the incidence of malpractice, healthcare providers must remain vigilant, prioritize thorough evaluations, and ensure timely and appropriate treatment for patients with suspected aortic dissection.