ER thoughts: John Ritter, lawsuits, and the aortic dissection

I just completed another shift in the emergency room (which I do about once per month), and it continually amazes me the amount of non-emergent cases that comes through – but that’s for another rant.

So I’m reading that the family of John Ritter is suing the hospital for misdiagnosing his ascending aortic aneurysm. Galen certainly has some tough words for this. I’ll reserve opinion since I’m not familiar with the case.

We’re taught there are generally four causes of chest pain that can result in sudden death. They are myocardial infarction, pulmonary embolus, aortic dissection, or tension pneumothorax. According to the story:

He was initially misdiagnosed with an acute myocardial infarction, then with pericardial tamponade, the suit states.

Generally, an aortic dissection needs to be suspected in order to be diagnosed – Medpundit has written about this today. 96 percent of dissections can be identified based on some combination of these symptoms:

1) Immediate onset of aortic pain with a tearing and/or ripping character,

2) Mediastinal and/or aortic widening on chest radiograph,

3) A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm).

Working in the ER, the first priority would be to ensure the cause is not one of the four “sudden death” causes. If the pattern didn’t fit an MI, a chest X-ray (routinely performed) would rule out a pneumothorax. That leaves dissection and pulmonary embolism as causes next to rule out. Chest CT would be the key test that would have caught the dissection (98 percent sensitivity). If PE was suspected, a CT angiogram would have been ordered.

Since the hospital’s working diagnosis was acute MI, and then pericardial tamponade (likely diagnosed via echocardiogram), I suspect that the chest CT wasn’t performed quickly enough, since dissection wasn’t high enough on their differential diagnosis (again, I’m just speculating).

I can only sympathize with the emergency room that night. With an acute aortic dissection, seconds count, and it was an unfortunate event for all concerned. Was it malpractice? Tough to say. The question I’d be interested in would be how long it took for the ER to order that chest CT scan.