Acute aortic syndrome (AAS) remains a significant clinical challenge due to the need for an urgent diagnosis and definitive surgical management.1 Point-of-care ultrasound (POCUS) may be useful for diagnosing AAS, also in a prehospital setting.2-4

An emergency medical team was dispatched for a 54-year-old man experiencing slurred speech and upper limb weakness. Upon arrival, the patient was conscious (Glasgow Coma Scale of 15). He reported experiencing a sudden collapse accompanied by speech disturbances and right-sided motor weakness during physical activity 2 hours earlier. On examination, he complained of discomfort between his shoulders (pain score, 4/10), intermittent speech difficulties, and paresthesia in his upper limbs. He denied any history of chronic illness and was not taking any medications on a regular basis.

A physical examination was performed using the ABCDE scheme. The airway was unobstructed (A). The respiratory rate was 20 breaths per minute, with oxygen saturation of 96% (B). On auscultation, a symmetrical alveolar murmur was present, and the heart rate was 65 bpm. Blood pressure was 110/80 mm Hg on the left arm and 130/80 mm Hg on the right arm (C). The right radial pulse was weakly palpable, and the capillary refill time was 4 seconds on the right side and 1 second on the left. Weakened muscle strength in the upper extremities was noted. The pupils were equal and symmetrically reactive. Meningeal signs were absent (D). The abdomen was nonpainful on palpation. The body temperature was 36.6 °C (E).

Twelve-lead electrocardiography showed sinus rhythm at 65 bpm, ST-segment elevation in the leads V1–V3, and a QS pattern in the leads V1–V2. POCUS performed by a paramedic using a mobile ultrasound device showed a large amount of free fluid in the pericardial sac, consistent with pericardial tamponade (Figure 1A and 1B). The ascending aorta was dilated (Figure 1C), and a dissection flap was visible in the suprasternal view (Figure 1D). Although the abdominal aorta was not dilated, it showed signs of complete dissection (Figure 1E and 1F) extending to the iliac arteries.

Figure 1. Imaging data of a patient with type A aortic dissection; A–E – point-of-care ultrasound imaging; A, B – pericardial effusion (arrows), subcostal 4-chamber view; C – dilated ascending aorta (arrow), parasternal long-axis view; D – dissection flap (arrow) in the aortic arch, suprasternal view; E – dissection flap (arrow) in the abdominal aorta; F – computed tomography scan performed immediately after admission to the hospital, visualizing aortic dissection (arrow)

The patient was diagnosed with Stanford type A aortic dissection, complicated by pericardial tamponade and ischemic stroke, in the prehospital setting. He was given fentanyl for pain relief and was urgently transported by air to a cardiothoracic surgery unit.

He underwent immediate surgery under deep hypothermia with extracorporeal circulation. An ascending aorta and arch repair was performed. The early postoperative course was complicated by ischemic stroke, pneumonia, and respiratory failure. The patient underwent a deferred procedure involving implantation of a branch stentgraft into the aortic arch and abdominal aorta. Six weeks after hospital admission, he was discharged home with residual hemiparesis.

Acute aortic dissection is a life-threatening condition. Patients with type A dissection may exhibit symptoms indicative of stroke or myocardial infarction.2 The well-documented mortality increase by 1%–2% for each hour following a type A dissection underscores the importance of quick, easily accessible diagnostic methods.4 Given its rapidity, portability, and safety, POCUS seems an ideal imaging technique for the initial evaluation of patients with suspected AAS.3 POCUS, in the hands of an experienced and qualified paramedic, enables immediate differential diagnosis and appropriate patient allocation, even in a prehospital setting.