title: Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection.
abstract: OBJECTIVE
  Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD.
  
  
  METHODS
  We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality.
  
  
  RESULTS
  Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27).
  
  
  CONCLUSIONS
  Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.
authors.affiliation: Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT. Electronic address: joseph.pare@yale.edu.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Pare
authors.affiliation: Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Rachel
authors.initials: R
authors.lastname: Liu
authors.affiliation: Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
authors.affiliation: Frank H. Netter, MD School of Medicine, North Haven, CT.
authors.forename: Tyler
authors.initials: T
authors.lastname: Sherban
authors.affiliation: Department of Radiology, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Kelleher
authors.affiliation: Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Sheeja
authors.initials: S
authors.lastname: Thomas
authors.affiliation: Department of Emergency Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT.
authors.forename: R Andrew
authors.initials: RA
authors.lastname: Taylor
mesh_terms: D000784:Aortic Dissection / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality; D001344:Autopsy / Q000706:statistics & numerical data; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data; D008875:Middle Aged; D009096:Multi-Institutional Systems / Q000706:statistics & numerical data; D015337:Multicenter Studies as Topic; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed