ER Case Study: How a Loss of Consciousness and Foot Pain Added Up to a Life-Threatening Diagnosis
Photo: JC Gellidon/Unsplash
In this ER case study, Dr. Zachary Levine catches us up on a case involving a woman who was brought in after losing consciousness.
The Case: A 65-year-old woman collapses at a store. She is unconscious for about 30 seconds. An ambulance is called, and the woman is brought to the emergency room (ER). The patient was normally healthy, known only to have high blood pressure (but was not on medication), and she also smoked on occasion. In the ER, she complains of severe left foot pain.
The Symptoms: She had suddenly lost consciousness. No faint feeling, no confusion, no seizure-like movements, so possibly an arrhythmia (an irregular heartbeat that does not effectively pump blood to the brain). But why the foot pain? So painful she required IV pain medications. Her heart rate and blood pressure were elevated, but all else was relatively normal.
The Tests: Electrocardiogram (ECG) and blood tests, a chest X-ray and a CT scan of the head. The ECG, a test to check heart function, showed evidence of strain; the chest X-ray showed a widened mediastinum (the area in the middle of the chest around the heart). So there was concern for heart strain and potentially a problem with the heart. Next, a CT scan focusing on the chest and the big blood vessels was performed.
The Diagnosis: The scan revealed aortic dissection, an uncommon but potentially deadly condition that happens when there is a tear in the wall of the aorta (the massive blood vessel that brings oxygenated blood from the heart to the rest of the body), and blood can flow between the layers of the blood vessel wall. It can affect the blood supply to the other organs it feeds. She had lost consciousness because the blood supply to her brain had temporarily been cut off. She also had severe pain in her foot because it was not getting an effective blood supply – a limb-threatening problem – as the dissection went from the aortic root at the top of the heart, all the way down to the groin where the aorta divides into left and right common iliac arteries and continues into the left common iliac artery.
The Treatment: Surgical correction – fix the tear and insert a graft to maintain proper strength and shape of the aorta. In this case, the surgeons also had to fix the iliac artery that was not adequately supplying blood to the patient’s left foot. The patient was hospitalized for one week after the procedure. She regained full use of her foot and did not have any neurological symptoms thereafter. While there was some strain put on the heart and kidneys due to the impact the tear in her aorta had on her body, there was no permanent damage.
The Outcome: The patient was discharged home in good condition with medications to control her blood pressure. She also stopped smoking — also a risk factor for aortic dissection. She continues to enjoy good health to this day and has regular follow-ups with her surgeons and her family doctor.
A version of this article appeared in the Jan/Feb 2019/20 issue with the headline, “This Month in the ER,” p. 30.