CCDHB EmErgEnCy DEpartmEnt CliniCal guiDElinE for aCutE aortiC DissECtion
Consider Acute Aortic Dissection (AD) in patients presenting with:
▪  Chest, back or abdominal pain
▪  Syncope
▪  Symptoms consistent with perfusion deficit (CNS, mesenteric, 
myocardial or limb ischaemia)
Alternative diagnosis is evident
OR 
Medical history + Clinical examination + ECG
SMO considers Aortic Dissection Pathway 
STEMI – use ACS Guideline
+ SMO* review / discussion
not appropriate
AD is still considered possible differential
Unstable
Haemodynamic state
Stable
Focused bedside pre-test risk assessment
 ▪ Bedside echo by ED SMO*
(Score 1 for each high-risk box applicable).  
 ▪ Urgent Cardiothoracic consultation
Max score in any box is 1.
 ▪ Contact ICU
High risk conditions:
High risk pain features:
High risk examination features:
 ▪ Transfer to CT or theatre as directed by Cardiothoracic 
 
F Connective tissue disease
Consultant
Chest, back or abdominal pain described as any of 
 
F Evidence of pulse deficit - 
 
F Family history of aortic disease
the following:
 
» Pulse deficit
 
F Known aortic valve disease
 
F Sudden in onset
 
» Systolic BP difference (>20mmHg)
 
F Known thoracic aortic aneurysm
 
F Severe in intensity
 
» Focal neuro deficit (with pain)
 
F Previous aortic manipulation or cardiac surgery
 
F Ripping or tearing in quality
 
F Aortic diastolic murmur (new + with pain) 
 
F Hypotension or shock
AD present?
Yes
No
Low 
High 
risk score 0-1
risk score 2-3
Proceed to  
ED SMO* review.
'Aortic Dissection 
Consider an alternative 
 ▪ Chest x-ray
Management Pathway’
diagnosis
 ▪ D-dimer
Request CT Angiogram
 ▪ ED bedside echo
AND inform ED SMO*
 ▪ Early SMO* review, before results
immediately
 ▪ Wide mediastinum OR other sign of AD on CXR 
How to use this clinical guideline
 ▪ OR Positive d-dimer (>500 ng/ml) 
 ▪ OR Signs of AD on echo  
AD present?
This clinical guideline is a tool to guide clinical 
 ▪ OR SMO* opinion that AD is likely 
practice and standardise patient care. 
All negative
Any positive
Yes
No
It is not designed to replace individual clinician 
judgement and patient preference. Patient can exit 
ED SMO* review.
Request CT Angiogram
Proceed to  
ED SMO* review.
the decision pathway at any point. 
'Aortic Dissection 
Consider an alternative 
Consider an alternative 
Management Pathway’
If ACS is the suspected cause for presentation,  
diagnosis
diagnosis
the patient is not to enter this pathway.
AD present?
Yes
No
* Senior Registrar if SMO is unavailable, such as overnight
Proceed to  
ED SMO* review.
'Aortic Dissection 
Consider an alternative 
Management Pathway’
diagnosis
COMMS: 00124-1605

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