Answer and Explanation 1

1.  Answer C.  This patient is demonstrating signs of shock and presentation and a history that is suspicious for thoracic aortic dissection (TAD).  Choice A has some good ideas of getting an EKG and giving oxygen.  Nitroglycerin should not be given to a hypotensive patient.  Aspirin should probably not be given especially if it is proven that the patient is actively bleeding.  Choice B is also incorrect for the same reasons plus morphine should not be given to the hypotensive patient.  Choice D may seem like a good choice if the patient was  a straight forward chest pain.  Choice C is correct because this needs to be treated as a seconds to minutes emergency.  A CT Scan with IV contrast will be needed to confirm a case of thoracic aortic dissection.  In the case of a patient with CT scan anaphylaxis or a high creatinine you can try getting one without contrast but it will not tell your where the bleeding is coming from.  The best test if it is available is a transesophageal ECHO (TEE).  Having great IV access as well as having blood ready is essential in management of this patient.