(p. 688) Aortic dissection 

Aortic dissection represents a splitting apart of the layers of the aortic wall, with blood under pressure entering the dissection plane and propagating for long distances along the aorta. The pain is said to be the most severe that a human being can experience. Pain is felt substernally with ascending dissection and between the shoulder blades for descending dissection. A high degree of clinical suspicion is essential in order for the diagnosis not to be missed. Because the dissection process can impair any branch of the aorta, the patient may present with symptoms related to any organ in the body. D-dimer is 100% sensitive at detecting aortic dissection (but non-specific). The ‘Triple Rule-Out CT Scan’ can confirm the clinical suspicion of aortic dissection, while at the same time ruling-out the other two cardiac conditions that can take a patient’s life acutely. Ascending dissection (Type A) is a surgical emergency because of the likelihood of intra-pericardial rupture. Descending dissection (Type B) is usually treated medically (with ‘anti-impulse’ therapy with β‎-blockers and afterload reducers). This condition is highly litigated and lethal if missed on initial presentation. Using D-dimer and liberal imaging will prevent mis-diagnosis and save lives.