St Emlyn’s Lesson Plans

Recognising acute aortic dissection

Use two presentations to practise recognising acute aortic syndrome and communicating the need for urgent senior assessment.

Medical Students · 45-minute session

For learners

Before: Allow about 12 minutes in total.

When we meet: We will compare two aortic presentations and practise explaining the concern to a senior clinician, including when an ECG suggests a competing diagnosis.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Handover sheet and current imaging/referral pathway.

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 12 minutes in total.

Core preparation

RCEM/RCR thoracic aortic dissection guideline, June 2026 · About 10 minutes

Read the summary on printed page 2, the presentation and diagnostic-test discussion on pages 4–5, and the high-risk features in table 1 on page 7. Focus on concerning history or examination findings and what a normal routine test cannot exclude.

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

Think about (allow 2 minutes): Why would abrupt severe pain still concern you after it has settled and the ECG is normal?

Picture the scene

A 73-year-old had severe chest pain that was maximal at onset. It has settled and they are reading comfortably. The ECG is normal and the blood pressure is high.

By the end of the session

Identify concerning pain, perfusion and risk-history features for acute aortic syndrome.
Explain why reassuring appearances or routine tests cannot independently exclude it.
Give a focused escalation handover and locate the local imaging/referral route.

After the session

Find the local aortic emergency pathway and rehearse locating the referral number before you need it.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 12 minutes in total.

Before learners arrive

Open the June 2026 guideline and your local CT-aortogram request route.
Identify the regional aortic service and transfer escalation contacts. Use the written findings supplied here or appropriately licensed teaching images.

Equipment: Handover sheet and current imaging/referral pathway.

Setup: Pairs prepare a 30-second escalation call; another pair identifies which missing fact would alter urgency.

If the preparation has not been completed

Replace “Prepare together” with five minutes using the case and table 1 on page 7 of the RCEM/RCR guidance. Allow two minutes to identify concerning history and examination features, two to give a brief senior handover, and one to name the local urgent imaging route. The facilitator supplies that local route.

Suggested session plan

0–5 min — Explore. Ask whether settled pain removes the concern raised by its abrupt onset.
5–10 min — Prepare together. Identify the guideline’s high-risk clinical features.
10–32 min — Discuss & Apply. Use 11 minutes per case, with a brief phone-handover rehearsal at the end of each.
32–40 min — Consolidate. Ask pairs to give a short escalation handover and identify the local route to definitive imaging and aortic care.
40–45 min — Reflect & Transfer. Have learners locate the regional aortic referral contact and check with a supervisor how it is used.

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 stopped

A 73-year-old describes abrupt severe chest pain radiating to the back. BP 190/100; the examination and ECG initially appear unremarkable.

Add this information as the discussion develops:

The chest radiograph is reported as normal.
The patient asks whether they can leave because the pain has gone.

Ask the group:

What part of the history remains concerning?
Which examination would you complete, and why?
How would you explain the need for senior review despite reassuring tests?

Discussion notes

Points to draw out:

Act on the clinical pattern and seek prompt senior assessment. Check pulses, perfusion, neurological findings and relevant aortic history while monitoring the patient.
A normal ECG, chest radiograph or settled pain does not independently exclude acute aortic syndrome.
The responsible team should discuss appropriate definitive imaging with radiology using the local pathway; ECG-gated CT angiography is central for many patients.
D-dimer alone must not be used to rule out thoracic aortic dissection.

Common misconceptions:

Waiting for ‘tearing’ as an essential adjective.
Thinking hypertension is reassuring because the patient is not shocked.
Ordering a routine chest CT and assuming it answers every vascular question.

For a more experienced group: Discuss why structured risk assessment is used selectively rather than scoring every chest-pain attendance.

An ischaemic ECG with a different story

A 68-year-old has abrupt neck/chest pain, hypotension and inferior ST elevation. The pain was maximal immediately; the team is preparing a coronary pathway.

Add this information as the discussion develops:

New focal neurological symptoms are reported.
Bedside ultrasound by an experienced clinician identifies a pericardial effusion.

Ask the group:

Which competing time-critical diagnoses require senior discussion?
Why can an ECG showing infarction coexist with dissection?
Who needs to join the assessment and organise definitive care?

Discussion notes

Points to draw out:

Acute aortic pathology can compromise coronary or other arterial flow and cause tamponade. The learner’s task is to communicate the conflicting findings promptly.
Senior EM, cardiology, relevant aortic surgical and critical-care teams should coordinate investigation and treatment.
Bedside ultrasound can identify complications but a negative scan does not exclude dissection. Medication and transfer decisions require the responsible clinicians; avoid reflex treatment that ignores the differential.

Common misconceptions:

Assuming the coronary tracing makes the history irrelevant.
Delaying aortic-team discussion until all paperwork is complete.
Interpreting a student ultrasound view as a rule-out test.

For a more experienced group: Map who accepts a patient with ascending-aortic involvement and who arranges an urgent transfer in your region.

Important clinical points

Negative D-dimer alone cannot exclude dissection.
Normal chest radiography or absence of a pulse differential cannot safely dismiss a concerning history.
A possible acute aortic syndrome needs urgent senior involvement before the learner treats it as uncomplicated ACS or PE.

Closing the session

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

Explain why pain resolution does not equal resolution of risk.
Give the key sentence in your escalation call.
Identify which local team arranges imaging and definitive aortic care.

Key teaching points:

Ask about pain onset and look for evidence of impaired perfusion.
Reassuring routine tests do not independently exclude acute aortic disease.
Communicate the concern early so that imaging and specialist care can be coordinated.

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

Risk-score/D-dimer strategies require careful selection and local implementation; the 2026 guideline notes that prospective validation remains needed. Do not teach them as a stand-alone student discharge rule.

If the discussion drifts

What exactly makes you concerned, and who needs that information now?

For a more experienced group

Compare the questions answered by gated aortic CTA, CTPA and echocardiography, and how instability affects the plan.

A 30-minute version

30 minutes: opening 3, features 5, first case 10, second case 7, consolidation 3, reflection 2.

Evidence and guidance

RCEM/RCR thoracic aortic dissection 2026 — Current national recognition and imaging guidance; June 2026 revision.https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf