St Emlyn’s Lesson Plans

Recognising acute aortic dissection

Discuss when to suspect aortic dissection and how to arrange imaging and specialist care without delay.

Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 13 minutes in total.

When we meet: We will discuss a comfortable patient with concerning symptoms and an unstable patient whose ECG suggests myocardial ischaemia.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Local pathway, a blank call/handover sheet, timer and optional approved ECG/echo images. The text case works without images.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 13 minutes in total.

Core preparation

RCEM/RCR: Diagnosis of thoracic aortic dissection in the ED · About 10 minutes

Read the six summary recommendations and the discussion of normal tests and risk scores in the June 2026 RCEM/RCR guideline. The facilitator will bring the local imaging and referral pathway.

https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf

Think about (allow 3 minutes): Which details would keep you concerned about aortic dissection after the pain had settled?

Picture the scene

A 73-year-old had sudden severe chest pain. It has now resolved and they are reading a newspaper in majors. The normal ECG is making everyone feel better.

By the end of the session

Identify history and examination features that should maintain concern for acute aortic syndrome.
Use the agreed local imaging pathway without relying on a normal ECG, chest X-ray or isolated blood test.
Communicate a coordinated resuscitation and specialist plan when dissection and coronary occlusion both remain possible.

After the session

Locate the overnight CT-aortogram and cardiothoracic referral route before your next shift.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 13 minutes in total.

Before learners arrive

Bring the current local CT-aortogram protocol, radiology contact, referral centre and transport arrangements for both working hours and overnight. If a contact or process is unclear, identify who can resolve it rather than asking learners to invent a route.
Identify a senior colleague who can clarify local anti-impulse treatment and unstable-patient imaging decisions. The session can expose pathway gaps; it should not invent a policy.

Equipment: Local pathway, a blank call/handover sheet, timer and optional approved ECG/echo images. The text case works without images.

Setup: One group manages the stable case and one maps the unstable case’s parallel tasks. Ask a learner to act as radiologist or receiving clinician and request missing information.

If the preparation has not been completed

Replace the five-minute opening with the hook and the six RCEM/RCR summary recommendations. Give pairs three minutes to read, then two minutes to identify why settled pain and a normal ECG do not close the assessment. Use the local pathway during the case rather than expecting learners to know its contacts. In the 30-minute plan, use five minutes here and reduce the stable case from 10 to eight minutes.

Suggested session plan

0–5 min — Pain that has settled. Read the hook and invite a provisional plan before revealing the transient leg symptom.
5–18 min — Assessment and CT request. Make the group state the clinical question, requested scan and who owns follow-through.
18–33 min — Competing emergencies. Explore the ECG/shock case and prevent the discussion becoming a simplistic either/or diagnosis.
33–40 min — Local pathway rehearsal. Practise a short referral and identify an actual contact or process gap.
40–45 min — Close. Ask each person for one situation in which a normal test would not reassure them.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

The pain has gone

A 73-year-old describes abrupt severe chest pain maximal at onset. It lasted twenty minutes and is now absent. BP is 190/100; ECG has no acute ischaemic changes. They ask whether they can leave.

Add this information as the discussion develops:

Ask what additional history and examination would change suspicion before offering imaging choices.
Reveal transient left-leg weakness during the pain, now resolved.
The CT radiographer asks which scan and which clinical question is being requested.

Ask the group:

Which features are being given too much reassuring weight?
What do you need to communicate to the senior clinician and radiologist?
Who owns the scan request and acts on the result?
What is the plan while imaging is arranged?

Discussion notes

Points to draw out:

Abrupt maximal pain, associated neurological/limb features, relevant aortic disease and examination findings belong in the risk assessment. Pain resolution is not exclusion.
The June 2026 RCEM/RCR guidance emphasises that normal ECG, chest radiograph and blood tests do not reliably exclude dissection. Use an agreed pathway with rapid CT-aortography access and active ED responsibility for requesting and acting on results.
The June 2026 guidance describes ADD-RS with D-dimer as emerging evidence requiring further prospective validation. Do not use negative D-dimer alone to rule out dissection. Scores should be confined to patients in whom dissection is a reasonable possibility, within the agreed pathway.

Common misconceptions:

Closing the differential when the pain settles.
Passing the imaging decision to another team without an accepted handover.

For a more experienced group: Ask learners to make the same decision with limited history because of language barriers; use a professional interpreter rather than guessing.

ST elevation with shock

A 68-year-old has sudden chest and neck pain, distended neck veins, BP 90/50 and inferior ST elevation. The nurse is preparing the primary-PCI call.

Add this information as the discussion develops:

Ask for simultaneous actions rather than choosing a single specialty.
Bedside echo by an appropriately trained clinician shows pericardial fluid.
The cardiothoracic centre asks about imaging, haemodynamics and transfer readiness.

Ask the group:

How could dissection and myocardial ischaemia coexist?
What can bedside echo help establish, and what can it not exclude?
Which standard chest-pain treatments need a senior pause because the competing diagnosis matters?
How will you avoid losing time in sequential specialty calls?

Discussion notes

Points to draw out:

Resuscitate and involve senior ED, cardiology and relevant surgical/critical-care teams early. A positive coronary-looking ECG does not make the wider history irrelevant.
Echo can identify important complications in an unstable patient but a negative bedside study does not exclude aortic dissection. The safest imaging strategy depends on stability and specialist availability.
Use the confirmed diagnosis and specialist plan to guide blood-pressure management, antithrombotics and transfer. Do not give a universal blood-pressure drug recipe to a hypotensive patient. Avoid presenting pericardiocentesis as a routine solution to suspected dissection-related tamponade.

Common misconceptions:

Treating the ECG without integrating the abrupt pain and shock.
Waiting for a perfect diagnosis before beginning coordinated escalation.

For a more experienced group: Rehearse a call in which the receiving centre is unavailable; identify who escalates while care continues.

Important clinical points

A normal ECG or chest radiograph does not rule out dissection.
Avoid uncritical antithrombotic or hypotensive treatment when the presentation suggests competing aortic pathology.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

What has the normal ECG actually excluded?
How would you make the CT request actionable?
Which calls should happen in parallel?

Key teaching points:

Pain may settle and the examination may be unremarkable despite dissection.
The ED should arrange the indicated scan and act on its result.
In an unstable patient, resuscitation, imaging decisions and specialist discussions need to proceed together.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

No bedside sign or single biomarker safely excludes every dissection. Specialist judgement matters, particularly in unstable patients. The role of risk scoring must match the locally agreed pathway.

If the discussion drifts

What dangerous possibility remains, and what concrete action will resolve it fastest?

For a more experienced group

Review a locally anonymised missed or delayed diagnosis, focusing on information flow and system response rather than hindsight blame.

A 30-minute version

30-minute option: opening 3, stable case 10, unstable case 12, local pathway and closing 5. Omit extended score debate.

Evidence and guidance

RCEM/RCR: Diagnosis of thoracic aortic dissection in the ED — June 2026 guidance on rapid CT access, responsibility for results and specialist referral.https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf