Add: new complex aortic emergency management question for critical ca…

…re scenarios

questions/cardiology/acute/complexAortic.md

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+---
+id: CARD012
+specialty: cardiology
+topic: aortic emergencies
+difficulty: hard
+tags: [cardiovascular, critical_care, vascular, emergencies, claude35Sonnet]
+created: 2025-01-10
+lastUpdated: 2025-01-10
+---
+
+# Complex Aortic Emergency Management
+
+## Question
+A 58-year-old man with poorly controlled hypertension presents with sudden-onset chest and back pain. Notable findings:
+
+Vital Signs:
+- BP: 185/95 mmHg (R arm), 125/70 mmHg (L arm)
+- HR: 105/min
+- RR: 22/min
+- SpO2: 96% on RA
+- Pain score: 9/10
+
+Additional History:
+- Prior aortic root dilation 4.5 cm
+- Family history of Marfan syndrome
+- Recent cocaine use 6 hours ago
+- Initial troponin negative
+
+Physical Exam:
+- New diastolic murmur
+- Asymmetric pulses
+- Focal neurological deficits: Left-sided weakness
+- Signs of malperfusion: Cool left arm
+- No signs of HF
+
+Initial Imaging:
+- CXR: Widened mediastinum
+- ECG: LVH with strain pattern
+- Bedside echo: Moderate AR, dilated root
+- CT scanner currently non-functional
+
+Which immediate management step is most appropriate?
+
+## Options
+| Option | Description |
+|--------|-------------|
+| A)     | Transfer to nearest cardiac surgery center (45 min away) |
+| B)     | Start esmolol drip, then obtain MRA |
+| C)     | Emergency TEE in ED for definitive diagnosis |
+| D)     | Thrombolysis for possible stroke |
+| E)     | Wait for CT repair (estimated 2 hours) |
+
+<details>
+<summary>View Answer</summary>
+
+## Correct Answer
+A
+
+## Explanation
+This represents likely acute aortic dissection with multiple high-risk features:
+
+1. Classic Findings:
+   - BP differential >20 mmHg
+   - Asymmetric pulses
+   - New AR murmur
+   - Neurological deficits
+   - Widened mediastinum
+
+2. Why Option A is optimal:
+   - High pretest probability
+   - Multiple risk factors present
+   - End-organ malperfusion
+   - Time-critical condition
+   - Need for surgical intervention
+
+3. Why other options fail:
+   - B) Delay without definitive care
+   - C) Delays transfer, limited utility
+   - D) Contraindicated if dissection
+   - E) Unacceptable delay
+
+4. Risk Factors Present:
+   - Hypertension
+   - Cocaine use
+   - Family history
+   - Known aortopathy
+   - Male gender
+
+5. Critical Care Points:
+   - Control BP with beta blockade
+   - Arrange emergent transfer
+   - Prepare for deterioration
+   - Monitor end-organs
+   - Consider blood products
+
+## References
+- NEJM 2023: "Acute Aortic Syndromes"
+- Circulation 2022: "Management of Acute Aortic Dissection"
+- JACC 2021: "Risk Stratification in Aortic Emergencies"
+</details>