Type A Aortic Dissection Pre Transfer

I: You are the ICU registrar on a nightshift

S: Outreach/Outliers registrar calls and says that she/he is transferring a hypertensive crisis to the unit straight from the CT scan

B: 52M patient, smoker, otherwise fit and healthy presented to A&E 2 hours ago with sudden onset chest pain. Lines inserted while awaiting transfer to CT.

A: Normal ECG, awaiting CTPA report

R: Called as the patient has just arrived to the unit.

• Initially A own, B SpO₂ 92% on 4L NC. C HR100 bpm, SR, BP 200/96, D awake, oriented, complaining of pain in the centre of his chest
• Starts becoming more tachycardic. If assessed- bilateral upper limb weakness 3/5.
• Radiology consultant on call calls- type A dissection involving ascending aorta, carotid arteries and aortic arch.
• Contact vascular surgeons and tertiary centre – start organising the emergency transfer
• Can call in a second registrar for help
• Continues to stabilize the patient- appropriate infusions and interventions before transfer (short acting iv beta blockers, short acting iv antihypertensives)
• If appropriate blood pressure control not achieved- patient starts to drop blood pressure with rising lactate and dropping Hb.
• Calls the on call consultant for help.

• Initial settings:    
  • SpO₂ 92% on 4L NC
  • RR 18/min
  • HR100 bpm SR
  • BP 200/96

• Progress to:       
  • SpO₂ 90% on 4L NC
  • RR 20/min
  • HR 110bpm SR
  • BP 210/100

• If beta blockers and antihypertensives started:
  • SpO₂ 92% on 4L NC
  • RR 20/min
  • HR 70 bpm SR
  • BP 160/70

• If appropriate medications not commenced:
  • SpO₂ 88% on 4L NC
  • RR 28/min
  • HR 120 bpm SR
  • BP to 100/40

• Further observations depend upon actions

Bedside Nurse 1:

• You are a critical care nurse
• You have teaken handover from a resus nurse of a patient who is complaining of chest pain. Handed over to you as a hypertensive crisis and was brought to ICU straight from CT.
• The registrar is at the bedside with you.
• You are concerned because the patient looks pale and sweaty, unlike a hypertensive crisis patient.
• You take direction well, and can perform tasks asked if you in a timely fashion
• You are helpful and prompt the candidate ‘is there anything else we should do?’, ‘should I run a gas?’, ‘has the line been x-rayed and is safe to use?’.

Bedside Nurse 2:

• You are a new starter – you have never seen someone so hypertensive before
• You are quite startled when asked questions/given directions, requiring instructions to be repeated to you
• If the candidate names equipment using technical terms then you inform them that you don’t know what that is; you are also not familiar with the IV medications as you have never used them before
• You are keen to help, but are unwilling to do anything beyond your skill set