Case

An 88-year-old female with a history of hypertension, hyperlipidemia, congestive heart failure, coronary artery disease status post-stents, atrial fibrillation (on Eliquis) and an ascending aortic aneurysm, presented to the Emergency Department with sudden-onset epigastric pain associated with shortness of breath. The pain was described as sharp. She denied trauma, exertion, chest pain, nausea or vomiting. She was in no acute distress on arrival but appeared uncomfortable.

Initial vital signs were: temperature 98.8 F, heart rate 76 bpm, respiratory rate 18 breaths/min, blood pressure 182/79 mmHg (right arm), 185/77 mmHg (left arm) and oxygen saturation 94% on room air. Physical exam revealed an uncomfortable appearing female with rales in all lung fields and bilateral pitting edema. No murmurs were heard and no focal neurologic deficits were noted.

Given the patient’s history of an ascending aortic aneurysm and presentation with elevated blood pressure, a focused cardiac ultrasound (FOCUS) was performed due to suspicion for acute aortic syndrome. The parasternal long axis view demonstrated a dilated aortic root measuring 6.4 cm with an intimal flap visualized in the ascending aorta (Figure 1). Based on these findings, the Cardiothoracic Surgery service at a tertiary care center was emergently consulted and arrangements were made for transfer. A subsequent computed tomography angiography (CTA) of the chest confirmed a Stanford Type A aortic dissection extending from the aortic valve through the aortic arch, with no extension into the descending thoracic aorta (Figure 2). The patient was then emergently transferred for Cardiothoracic Surgery service evaluation. Recognition of the dissection on FOCUS allowed for earlier surgical involvement and expedited transfer to a tertiary center while confirmatory CTA imaging was obtained.

Discussion

Thoracic aortic dissection is a life-threatening condition with an estimated incidence of 3 per 100,000 person-years and a mortality rate that increases by 1–2% per hour in untreated Stanford Type A dissections.¹ Early diagnosis is crucial, yet challenging, due to variable presentations that may mimic other emergencies, such as acute coronary syndromes.² A high index of suspicion and rapid access to diagnostic imaging are essential to reduce mortality.

While CTA remains the diagnostic gold standard, FOCUS has emerged as an increasingly valuable bedside tool for early detection of aortic dissection. The use of FOCUS by emergency physicians allows for rapid assessment of the heart to identify a pericardial effusion and of the thoracic aorta for features such as aortic root dilation, aortic regurgitation and the pathognomonic finding of an intimal flap.³ The ability of FOCUS to aid in early identification and management of aortic dissection has been emphasized by both the American Society of Echocardiography and the American College of Emergency Physicians in joint consensus guidelines.⁴

Several studies have demonstrated that FOCUS performed by emergency physicians has high diagnostic accuracy and is feasible for detecting thoracic aortic dissection, particularly in the evaluation of the ascending aorta.⁵ The diagnostic performance of FOCUS in patients with suspected acute type A aortic dissection varies depending on the findings assessed. When limited to direct signs, such as an intimal flap or intramural hematoma, the sensitivity was 54% and specificity was 94%. However, when both direct and indirect signs (including ascending aorta dilation, aortic valve insufficiency or pericardial effusion) were evaluated together, sensitivity improved to 88% at the expense of specificity, which decreased to 56%, reflecting a trade-off between broader screening utility and diagnostic precision.⁶ A more recent study utilizing the direct sonographic sign of an intimal flap, alongside indirect findings such as pericardial effusion and a more conservative threshold for aortic outflow diameter >35 mm (measured inner wall to inner wall) reported an improved sensitivity of 100% for detection of type A aortic dissection.⁷ This protocol noted that the sonographic evidence of an intimal flap was 100% specific for aortic dissection and the absence of aortic outflow dilation of >35 mm demonstrated 100% sensitivity for ruling out type A dissection. Critics of the study, however, comment that none of the patients diagnosed with type A dissection in this study exhibited a dilated aortic root, which may not be a universal finding. Therefore, reliance on the indirect criterion of aortic outflow dilation >35 mm alone to exclude type A aortic dissection should be approached with caution.⁸

As in this case, FOCUS has been shown to improve early diagnostic rates of ascending aortic dissection and can expedite confirmatory imaging and surgical consultation. Pare et al. showed a decrease in the time to diagnosis of aortic dissection by an average of 146 minutes in patients receiving FOCUS compared to patients who did not.⁹ Additionally, case reports have documented instances in which FOCUS identified dissection in patients initially misdiagnosed with conditions such as ST-elevation myocardial infarction, emphasizing its role in avoiding diagnostic errors and mismanagement.¹⁰ The inclusion of suprasternal and subcostal windows in thoracic aorta evaluation has been recommended to improve visualization and diagnostic yield in the emergency department setting.¹¹

In this case, FOCUS revealed a dilated aortic root and an intimal flap in the parasternal long axis view, prompting emergent surgical consultation for an expedited transfer and definitive care. This aligns with prior literature showing that early identification of dissection using FOCUS can significantly influence time to diagnosis and treatment.⁹ While not a replacement for CTA, ultrasound can guide clinical decision-making and shorten time to diagnosis, particularly in resource-limited or high-acuity settings.

Case Conclusion

The patient remained hemodynamically stable in the emergency department following diagnosis and was transferred expeditiously to a tertiary care center for cardiothoracic surgical evaluation and further management.

Indications

• Blood pressure or pulse asymmetry between limbs (>20 mmHg)
• Chest, back or abdominal pain, usually sudden onset, severe, especially described as “tearing” or “ripping”
• Diastolic murmur (new), especially aortic regurgitation
• Hemodynamic instability in a patient in whom CT is not immediately feasible
• High clinical suspicion of aortic dissection
• Widened mediastinum on chest radiograph

Technique

• Place the patient in a supine position.
• Apply ultrasound gel to a low frequency phased array transducer.
• Use a parasternal long axis view to assess for direct signs of dissection such as an intimal flap (seen in this case) or an intramural hematoma.
• Assess for secondary signs of dissection which may include ascending aorta dilatation, aortic valve insufficiency (seen with color Doppler) or a pericardial effusion with or without tamponade.
• Measure the widest portion of the proximal ascending aorta, past the Sinuses of Valsalva, in end diastole, placing calipers leading edge to leading edge of the aortic wall.¹²
• Use the suprasternal notch view to evaluate the aortic arch.

Pitfalls and Limitations

• Decreasing the cutoff for abnormal aortic outflow diameter measurement from 4 mm to 3.5 mm may increase sensitivity; however, further studies are needed to validate this and it is likely to decrease the specificity.
• Negative FOCUS does not rule out dissection, especially in Type B cases or in patients with technically difficult imaging as sensitivities in the literature vary widely.
• Not all dissections are visible on transthoracic and transesophageal echocardiography; CTA is often required and recommended when feasible.
• Operator skill and patient anatomy heavily affect diagnostic yield.
• Visualization of the ascending aorta and aortic arch may be limited by body habitus.

References

1. Howard DPJ, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control. Circulation. 2013;127(20):2031-2037. doi:10.1161/CIRCULATIONAHA.112.000483
2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA Guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 2010;121(13):e266-e369. doi:10.1161/CIRCULATIONAHA.110.958984
3. Wang Z, Chen X, Wei Y, et al. Diagnostic accuracy of transthoracic echocardiography for acute type A aortic dissection: a systematic review and meta-analysis. Medicine (Baltimore). 2019;98(44):e17719. doi:10.1097/MD.0000000000017719
4. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-1230. doi:10.1016/j.echo.2010.10.005
5. Thomas W, Henry J, Chew JE, Premaratne M, Blecher G, Haji DL. Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: a systematic review and narrative synthesis of the literature. Emerg Med Australas. 2023;35:720-730. doi:10.1111/1742-6723.14262
6. Nazerian P, Vanni S, Castelli M, et al. Diagnostic performance of emergency transthoracic focused cardiac ultrasound in suspected acute type A aortic dissection. Intern Emerg Med. 2014;9:665–670. doi:10.1007/s11739-014-1080-9
7. Gibbons RC, Smith D, Feig R, Mulflur M, Costantino TG. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. Acad Emerg Med. 2024; 31: 112-118. doi:10.1111/acem.14839
8. Gottlieb M. SPEED of sound: The role of ultrasound in aortic dissection. Acad Emerg Med. 2024; 31: 201-203. doi:10.1111/acem.14885
9. Pare JR, Liu R, Moore CL, et al. Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection. Am J Emerg Med. 2016;34(3):486-492. doi:10.1016/j.ajem.2015.12.005
10. Chenkin J. Diagnosis of aortic dissection presenting as ST-elevation myocardial infarction using point-of-care ultrasound. J Emerg Med. 2017;53(6):880-884. doi:10.1016/j.jemermed.2017.08.012
11. Taylor RA, Moore CL. Point-of-care ultrasonography of the thoracic aorta. In: Connolly JA, Dean AJ, Hoffmann B, Jarman RD, eds. Emergency Point-of-Care Ultrasound. Wiley Blackwell; 2017. doi:10.1002/9781119072874.ch3
12. Lang, R. M., Badano, L. P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L., … & Voigt, J. U. (2015). Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European Heart Journal-Cardiovascular Imaging, 16(3), 233-271..

Protecting Vulnerable Populations in Research: Are Vulnerable Populations Becoming More Vulnerable?

Neha Sikka, MD
PGY4/Chief Resident
Mount Sinai Hospital | Elmhurst Hospital in New York City

I was honored to receive one of the New York Young Physician and Resident Leadership and Advocacy Awards which allowed me to attend the national ACEP Leadership and Advocacy (LAC) conference for the first time this year. Since beginning residency, I have been interested in getting involved in the advocacy space and gaining a deeper understanding of the policy that shapes our broken healthcare system. I have participated in New York state advocacy days, health policy education at my residency and even spent a month in Washington DC with the national ACEP Advocacy office but found LAC was a great bootcamp of all things policy and advocacy.

The conference started out with a healthcare primer for residents and young physicians newer to the advocacy space. There were a series of great short talks by different trainees and a session on how to write a policy resolution. I especially enjoyed Dr. Sophia Spadafore’s lectures on reimbursement. Like many emergency medicine physicians, I find discussing reimbursement and pay unsavory. Dr. Spadafore did a great job highlighting the inherent faults in the current process to create and reimburse relative value units in a budget neutral matter and the bias toward surgical procedures. The lack of any inflationary increase in physician reimbursement – which also covers ancillary staff – is likewise shocking and threatens the sustainability of our medical professions.

The second day of the conference included more great education. The National ACEP advocacy team, including Ryan McBride, Jeanne Slade, Fred Essis, and Erin Grossman gave great primers on how our government creates legislation and regulates that legislation. Content experts spoke about how the No Surprises Act is regulated in a way that negatively impacts physicians rather than insurers, how minute-to-minute tracking can help find boarding solutions, advanced practitioner scope, Medicaid and EMTALA. The day was a good reminder of the intricacies involved in moving legislation in the federal government and the complications on carrying out passed legislation.

The third day was the most rewarding conference day. We heard from representatives Dr. John Joyce from Pennsylvania, Dr. Kim Schrier from Washington, Tom Suozzi from New York and Brian Fitzpatrick from Pennsylvania on legislative priorities and best practices for advocating in Congress, such as highlighting stories from practice and inviting representatives into our emergency departments. We discussed the RAND report “Strategies for Sustaining Emergency Care in the United States” which stated that there was $42.6 billion dollars of uncompensated care in 2020 and emergency departments lose $2.7 billion annually in uncompensated care for uninsured patients.

After these talks, we spent time on the Hill speaking to the offices of our representatives and senators about three different policies: (1) The Lorna Breen Act for Healthcare Worker wellbeing which was previously passed in 2020 after the suicide for EM physician Lorna Breen but is now up for reauthorization, (2) the ABC-ED act which uses existing CDC grant funding to track boarding statistics, and (3) sustaining emergency medicine care with a request to increase Medicare reimbursements and not cut Medicaid. It was a poignant time to advocate around Medicaid as the federal government is currently debating appropriations and how to cut the federal deficit and it has been rumored that Medicaid was proposed as a potential cut.

Overall, LAC was educational, fun and inspiring. I left with a better understanding of our healthcare system, the legislation and regulations that shape it and how emergency medicine is especially threatened by proposed changes. I feel empowered to continue to advocate on the national, state and city level and look forward to staying involved with ACEP Advocacy.

Jessica Ashley, MD MPH
PGY-5
Pediatric Emergency Medicine
NYP-Morgan Stanley Children’s Hospital at Columbia University Medical Center

I was thrilled to be a recipient of the 2025 Young Physician & Resident Leadership and Advocacy Award. This award allowed me to attend my first ACEP Leadership and Advocacy Conference (LAC) in Washington, DC. I consider it a real gift to be able to be a physician taking care of children and families in crisis. At each step along my journey to this point, I have revisited my personal mission of creating agency for those affected by systemic oppression, violence and inopportunity — individuals who do not always have the agency to determine their own paths. I have explored what this mission means as a physician, researcher, educator and advocate. I have been a participant and leader in minority physician recruitment and retention efforts, pipeline programming, administrative leadership, medical education and community partnership and education. My public health training, focused on environmental and occupational health, deepened my understanding of the systems that shape health circumstances, heavily informing my approach to the aforementioned roles. This award from New York ACEP opened a door to a vast and incredibly important approach to my mission: national legislative advocacy. I left with three resonant sentiments:

• As the role of a physician evolves over time, we see more and more physicians in hospital administration and leadership, journalism, narrative medicine, public health and in public office! There are currently 21 physicians in US congress – 4 senators and 17 house representatives – who hold positions in both major parties. While we do not all need to be senators or house representatives, our education and experience hold weight in these offices. Our role extends beyond the emergency department and our voices and experiences are necessary to build a system that works. Whether a resident, a fellow, junior or senior faculty, our direct experience of the system is necessary for those in public office to understand what their constituents need from them. Being in these hallowed offices and having my voice matter was an incredible experience validating the time invested in understanding what the communities we serve need from us, how best we as a medical system can meet those needs and what we as emergency physicians need from policy and public infrastructure in order to get there.
• While the day on Capitol Hill was a real highlight of LAC, the policy education was also an unparalleled experience. The rapid, accessible and highly relevant sessions over the first two days of LAC gave me context I needed to understand my experience of the health system. They gave me the language to describe what I have seen and felt subjectively. Building this language and understanding was a pivotal part of my time at LAC. Health policy education is something we all need to better understand a major component of social determinants of health and to better understand how to advocate for a better healthcare system.
• Lastly, my time at LAC was a true testament to the power of collaboration and communication. To be in a room with so many impressive speakers and attendees was humbling. Physicians from around the country with a wide array of backgrounds and beliefs came together with passionate energy to share, listen and learn from one another. In a political climate of mounting divisiveness, we were taught strategies to communicate across party lines. We identified shared goals with officials across multiple political ideologies and targeted our advocacy efforts towards important, actionable, practical and tangible outcomes.

I left LAC feeling empowered and inspired by this community of emergency medicine physicians and the power we have to influence change together. I am so grateful to New York ACEP for awarding me the opportunity to participate in LAC. I am a far better physician advocate for this experience.

Brief Resolved Unexplained Events

Introduction

For parents and caregivers, there are few things more unsettling than a well-appearing infant who suddenly stops breathing, becomes cyanotic or becomes limp. These presentations, though often resolved by the time the infant reaches the Emergency Department (ED), can have both benign and more serious etiologies. For emergency medicine physicians, these presentations can trigger extensive workups and hospital admissions.^1,2

In 2016, the American Academy of Pediatrics (AAP) sought to bring clarity and structure to this clinical dilemma by introducing the term Brief Resolved Unexplained Event (BRUE) and developing a BRUE clinical practice guideline. A BRUE is defined as a sudden, brief (typically less than one minute) and resolved episode in an infant under 12 months of age, characterized by one or more of the following:

1. cyanosis or pallor
2. absent or irregular breathing
3. a marked change in tone (either hypo- or hypertonia)
4. altered level of responsiveness^1,2

A BRUE has no discernible etiology based on history and physical examination and the infant must be back to baseline at the time of evaluation.¹

The term BRUE replaced the broader and often inconsistently applied term “Apparent Life-Threatening Event” (ALTE). The term ALTE received criticism for its vagueness, heavy reliance on caregiver interpretation, need for excess diagnostic investigation and poor correlation with outcomes. This change represented a shift towards risk stratification, evidence-informed management and greater diagnostic precision. The goal of replacing ALTE with BRUE and developing a BRUE clinical practice guideline was to identify infants at higher risk for adverse outcomes and avoid unnecessary workup of infants who are at lower risk.

Approach to History and Physical Exam

Evaluating a potential BRUE begins with an in-depth history. Obtaining a detailed description of the episode (color change, tone alteration, respiratory pattern, duration and responsiveness) is essential. The infant’s sleeping and feeding patterns, behavior and activity level and any recent infectious symptoms are also useful in understanding the context of the patient’s presentation. A thorough birth history including prematurity and NICU or nursery events should be obtained to understand prenatal and perinatal risk factors. Family history of cardiac, metabolic, genetic or neurologic conditions and any history of sudden infant death syndrome (SIDS) or other sudden death may be relevant. A social history should also be obtained to assess for changes in caregivers, exposure to toxins or medications and recent injuries.

A thorough physical examination including vital signs is necessary for diagnosis and risk stratification. An infant should be diagnosed with a BRUE only if well-appearing on exam and a BRUE is considered lower risk only if the exam is normal. Abnormal exam findings warrant further appropriate workup and patients with an abnormal exam should not be diagnosed with a BRUE. In addition to conducting a complete exam including the cardiac, respiratory and neurological systems, special attention should be given to signs of trauma and developmental delay.

Cases

Case 1

A 3-month-old male is brought to the ED after an episode of cyanosis at home. His mother noted that his face was purple while he was in his crib for a nap and it appeared he was not breathing. After his mother picked him up and patted his back, he began to cry and his color normalized within one minute. The patient has no history of similar symptoms in the past. He has had no fever, nasal congestion, cough, difficulty breathing, feeding changes, vomiting, diarrhea or rash. His last feed was about two hours prior to the event and he drank his normal four ounces of formula. He was born at 39 weeks gestational age via spontaneous vaginal delivery and had an unremarkable newborn nursey course. He has been growing appropriately, meeting his developmental milestones and immunizations are up to date. There is no family history of SIDS or other sudden death. On exam in the ED, the patient is awake and alert, drinking from a bottle. His vital signs are as follows: 37.1C, HR 128, RR 34, BP 82/56, SpO2 100% on room air. The remainder of his physical exam is normal for age. The patient is observed in the ED for two hours and discharged home with pediatrician follow up.

Case 2

A 5-week-old female is brought to the ED following a 30-second episode of facial cyanosis and stiffening/arching of her back. The episode occurred following a feed and a large episode of non-bloody, nonbilious emesis. The patient’s parents were alarmed because the patient appeared to have difficulty breathing and her father performed the Heimlich maneuver. The patient returned to baseline afterwards. A similar episode occurred the day before, but her symptoms self-resolved more quickly and without intervention. The patient has been feeding normally – she breastfeeds or drinks three ounces of formula every three hours. Her parents are unsure if she is vomiting because her spit ups have become more voluminous recently. She has had no recent fever, cough, congestion, fatigue or other cyanosis with feeds or abnormal jerking movements. She was born at 33 weeks via an uncomplicated vaginal delivery and required an 11-day NICU stay for supplemental oxygen (weaned after four days) and feeding support. She has no pertinent family history.

On exam in the ED, the patient is sleeping but easily arousable. Her vital signs are as follows: 37.7C, HR 139, RR 39, BP 70/42, SpO2 99% on room air. The remainder of her physical exam is normal for age. Her blood glucose level is 85 mg/dL. Her ECG shows normal sinus rhythm, normal intervals and normal axis. An abdominal ultrasound shows no pyloric stenosis. While in the ED, shortly after feeding, the patient has an oxygen desaturation to 88%. This resolves when the patient is picked up and held upright. After a sepsis workup is completed and empiric antibiotics are given, the patient is admitted for further evaluation. As the patient was born preterm, a head ultrasound is obtained and shows no intracranial hemorrhage or other abnormalities. The patient’s echocardiogram is normal. Antibiotics are discontinued after cultures are negative for 48 hours. Reflux precautions are initiated and the patient has no other events. She is discharged with pediatric and pediatric gastroenterology follow up.

Differential Diagnosis

As BRUE is a diagnosis of exclusion, physicians must consider other diagnoses for infants presenting with symptoms concerning for BRUE. The differential diagnosis can include the following:

• Respiratory: viral infections, particularly RSV and pertussis
• Cardiac: congenital heart disease, heart failure, arrhythmias such as long QT syndrome and other channelopathies
• Gastrointestinal: gastroesophageal reflux with laryngospasm, aspiration
• Neurologic: seizures, infantile spasm, intracranial hemorrhage or pathology
• Infectious: sepsis, meningitis/encephalitis, bacteremia, UTI
• Metabolic/Genetic: hypoglycemia, inborn errors of metabolism, toxic ingestion
• Trauma: accidental trauma, non-accidental trauma

History and physical exam findings should guide further consideration of the above diagnoses and targeted workup.

Disposition and Management

Infants meeting criteria for a lower-risk BRUE are unlikely to have a recurrent event or an undiagnosed serious condition and thus are at lower risk for an adverse outcome. Following are features required for categorizing a BRUE as lower risk: age > 60 days, gestational age ≥ 32 weeks and a post-conceptional age ≥ 45 weeks, event duration of less than one minute, no need for CPR by a trained provider, first occurrence and a normal history and physical exam.¹ Infants meeting these criteria are unlikely to benefit from additional diagnostic testing or hospital admission.^1,3 Observation in the ED may be appropriate for caregiver reassurance, but most infants can be safely discharged with education and anticipatory guidance. Discharge instructions should include counseling on safe sleep, feeding and CPR training and clear return precautions. Implementation of the BRUE clinical practice guideline has led to fewer unnecessary tests and hospital admissions, without an increase in missed diagnoses or adverse outcomes.^3,4

Infants who do not meet lower-risk criteria may require further evaluation depending on features present. Appropriate workup may include ECG, blood glucose level, CBC, blood and urine cultures, CSF studies, respiratory pathogen testing and imaging. Admission for monitoring and further evaluation may also be indicated. Though recurrence of BRUE and presence of an underlying serious condition are uncommon, further appropriate workup should be considered in patients who do not meet all lower-risk criteria to avoid missing rare but significant pathologic conditions.^5-7

Case Discussion

Case 1

This patient’s event was brief and is now resolved. His exam in the ED is normal and there is no alternative explanation based on history and physical and his presentation meets the BRUE definition. The patient is older than 60 days, was born at term, had a single event, did not require CPR and has no other concerning symptoms or findings on evaluation. Because he meets all criteria for a lower-risk BRUE, an adverse outcome is unlikely. Appropriately, he is not worked up in the ED and is discharged home after a brief observation period.

Case 2

This patient has several risk factors for a higher risk BRUE: age < 60 days, post-conceptional age < 45 weeks and a similar event the day before. Additionally, her exam is not normal as she develops hypoxia during observation in the ED. Because of the patient’s presentation, the differential diagnosis includes infectious, cardiac, neurologic and gastrointestinal etiologies. Further workup is indicated to rule out these etiologies as BRUE is a diagnosis of exclusion. Because of the patient’s hypoxia event, hospitalization is indicated for monitoring and workup. Once infectious, cardiac and neurologic etiologies are ruled out, the patient is diagnosed with and treated for reflux.

Conclusion

The BRUE clinical practice guideline allows physicians to avoid unnecessary workup and admission of infants presenting with typical features and lower-risk criteria based on a complete and careful history and physical exam. Patients who fall into the lower risk stratification are unlikely to have an adverse event. Thus, both clinicians and caregivers can be reassured that these patients can be discharged from the ED without further evaluation. However, patients who do not meet all lower-risk criteria may require an appropriate workup and admission.