Diagnosis of thoracic aortic dissection in the emergency department

The diagnosis of thoracic aortic dissection is often difficult to establish in emergency department (ED) patients attending with chest pain. This guideline that has been produced jointly between the Royal College of Radiologists and the Royal College of Emergency Medicine seeks to provide a consensus opinion with regards to which patients should be considered for CT scanning (the diagnostic modality of choice) whilst accepting that this is still an area of considerable controversy and concern.

This guidance was originally published in January 2024 and has since undergone minor amendments to reflect current best practices. 

Summary of recommendations 

1. All clinicians working in the emergency department should be made aware of the difficulties in excluding the diagnosis of Thoracic Aortic Dissection (TAD) and the need to be aware of local policies and resources to assist in this as part of their induction. 
2. Each emergency department must have agreed protocols between themselves and their radiology department regarding requests for CT Aortograms in cases of suspected thoracic aortic dissection. 
3. Thoracic aortic dissection is a time critical emergency and provision must be available for the ED to rapidly access CT Aortograms throughout the whole 24-hour period. 
4. If the ED suspects a patient has a TAD it is the role of the ED to request the scan and act on the result. This responsibility should not be passed onto another clinical team. 
5. All emergency departments should have a local protocol or pathway detailing the actions to be taken once a diagnosis of TAD has been made. This should include details of blood pressure management and local urgent referral pathways to specialist surgical centres, where appropriate.