Failure to diagnose aortic rupture in a timely manner
A woman came to the ED with pain, pressure, and tightness in the center of her chest.
by Rachel Pollock, Marketing and Brand Specialist
Presentation
A 60-year-old woman came to the emergency department (ED) of a large hospital center on February 22 with chest pain and pressure and tightness in the center of her chest. The patient reported that the pain began 20 hours earlier and had become severe.
The ED physician ordered an electrocardiogram (EKG) which revealed a first-degree intraventricular (AV) block, intra-atrial conduction delay, slight atrioventricular (AV) conduction delay, very pronounced left ventricular geometry (LVG), and marked high lateral depolarization disturbance. Labs showed a normal troponin level. The patient was treated with aspirin and nitroglycerin and was admitted to the hospital.
During a second exam, the patient reported that she was still experiencing tightness in her chest and that pain had spread to her jaw and ears. The patient’s blood pressure was 148/64 and her pulse was 56. A second EKG indicated signs of sinus bradycardia with first-degree AV block, left ventricular hypertrophy, and repolarization abnormality. A cardiac consult was requested.
Physician action
The cardiologist examined the patient and noted that the patient’s chest pain was retrosternal, left sided, and pleuritic. Her blood pressure was 135/63 and her pulse was 62. The cardiologist determined the patient had atypical chest pain and ordered a CT without contrast. The patient was treated with atorvastatin and aspirin.
The next morning, on February 23, the cardiologist was notified that the patient had developed atrial fibrillation. Additionally, an EKG showed her to have rapid ventricular response, voltage criteria for left ventricular hypertrophy, ST&T wave abnormality and to consider lateral ischemia. Rivaroxaban was initiated. By 8 a.m. her blood pressure was 143/75 and her pulse was 109.
A CT scan performed at 8:57 a.m. revealed slightly dense pericardial effusion measuring 17mm in thickness, possibly due to complex fluid. The CT scan also suggested dilation of the aortic root 5 cm, although this was poorly assessed without contrast, and wedge-shaped, pleural-based pulmonary opacity in the right lower lobe suggestive of pneumonia, scarring, or volume loss.
The cardiologist ordered a STAT surgical consult after receiving the CT scan information, which she believed showed an aortic root aneurysm.
On February 24 at 7:14 a.m. the cardiologist noted an echocardiogram (echo) performed the day before on February 23 showed ventricle enlargement and increased concentric left ventricular wall hypertrophy. At 9:45 a.m., the patient’s blood pressure was 87/46 and her pulse was 90.
At 11:24 a.m., the patient’s heart stopped. Life-saving measures were administered, but the patient died. The cause of death was listed as cardiac arrest due to aortic rupture.
Allegations
A lawsuit was filed against the cardiologist for failure to timely diagnose the aortic rupture, resulting in the patient’s death.
Legal implications
Consultants for the defense were not supportive of the cardiologist. An emergency medicine consultant stated that the failure to recognize the patient’s “impressive” heart murmur during the initial ED exam was a significant issue. If the murmur had been recognized, the patient could have received a STAT echocardiogram, which could have diagnosed the aortic root dissection. Then, the patient could have been taken to surgery immediately. Unfortunately, the murmur was not recognized.
In a statement, the cardiologist said that once she suspected the aortic root dissection on February 23, she ordered an urgent surgical consult. The cardiologist also stated that she asked a nurse to follow up with the surgeon on February 24, when she learned the patient had not been seen.
One consultant stated the cardiologist should have contacted the surgeon directly instead of relying on the nurse, especially since the consult was emergent.
Another weakness in the patient’s care occurred when the patient was prescribed anticoagulants after developing atrial fibrillation. A cardiology consultant stated anticoagulation was contraindicated due to the patient requiring emergent surgery.
Unfortunately, the cardiologist did not maintain adequate documentation on this patient. It was unclear from the records when the cardiothoracic surgeon consult was ordered. Many of the cardiologist’s notes on this patient were added to the record on February 25, a day after the patient died.
Disposition
This case was settled on behalf of the cardiologist.
More about diagnostic errors.
Disclaimer
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.
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