关键词: 主动脉疾病, 急性病, 急诊处理, 急诊室, 医院, 危险性评估, 滞留时间, 确诊时间

Abstract: Background　Acute aortic dissection （AAD） is a rare but fatal aortic disease if left untreated.Patients with continuous severe chest and back pain，high risk factors and obvious physical findings are hardly misdiagnosed or have a missed diagnosis，but those with atypical symptoms are difficult to be diagnosed timely.Therefore，it is urgent to formulate diagnostic framework for atypical AAD.Objective　To summarize a rapid emergency diagnostic and therapeutic procedure for atypical AAD，and to analyze the improvement in waiting time for a confirmed diagnosis and retention time in emergency department.Methods　We collected the clinical data of 91 AAD patients who had been diagnosed and misdiagnosed by Department of Emergency，Maanshan People's Hospital from January 2012 to December 2018，and divided them into typical AAD group（n=51） and atypical AAD group（n=40）according to clinical manifestations and final diagnostic results，then further divided atypical AAD patients into control subgroup （n=24，admitted from January 2012 to December 2015），and observation subgroup （n=16，admitted from January 2016 to December 2018） according to the admission time.We used two diagnostic procedures although efforts have been made to explore and improve the procedure since the first atypical patient had been found in our hospital in 2012.Before 2016，due to insufficient understanding of AAD，we diagnosed suspected AAD patients without performing examinations such as routine blood test，measurement of serum C-reactive protein，electrolytes，and amylase，ECG，liver and kidney functions，urine amylase，PT，APTT，TT and FIB，myocardial enzyme and CTnI，and D-Dimer，as well as CT scan when necessary.Since 2016，we used a different diagnostic procedure revised based on gradually improved understanding of atypical AAD gained by years of summary and learning of aortic disease-related knowledge and literature review，and the suspected AAD patients are diagnosed based on data including the aforementioned examinations，for those highly suspected，if the aforementioned examinations are not sufficient to make a confirmed diagnosis，aortic angiography was performed additionally.We compared the demographic data，missed diagnosis，misdiagnosis，time of confirmed diagnosis，retention time in emergency department，and outcome across the typical patients，control and observation atypical patients.Results　Sex ratio （χ2=0.024，P=0.989） and mean age （F=2.594，P=0.080） showed no significant differences across typical AAD group，control and observation atypical AAD subgroups.One observation atypical patient and 1 control atypical patient as well as 5 typical patients were misdiagnosed.The mean time for making a diagnosis for those with correct diagnosis in typical AAD group，control atypical AAD subgroup and observation atypical AAD subgroup was （27.6±16.8） min，（38.8±21.6） min，and （19.1±7.4） min，respectively，showing a significant difference（F=6.180，P=0.003）.The mean retention time in emergency department for typical AAD group，control and observation atypical AAD subgroups was 0，3.4（8.9） hours，and 1.5（1.0） hours，respectively.The control atypical AAD subgroup had a longer mean retention time in emergency department than observation atypical AAD subgroup （Z=-3.875，P<0.001）.77 patients were transferred to higher level hospitals，the other 12 patients were treated in our hospital，11 of whom received pharmacological treatment，and the other 1 received stent implantation.Two typical AAD patients died within 1 hour after diagnosis.Conclusion　To improve the diagnostic accuracy of atypical AAD to save time for further treatment，measurement of D-Dimer and CT scan or together with CTA when necessary should be performed for suspected atypical AAD patients during the initial examination as far as possible.In addition，learning of clinical symptoms and imaging features of atypical AAD should be strengthened in front-line clinicians and emergency diagnostic and therapeutic procedure for atypical AAD should be standardized.

Key words: Aortic diseases；Acute disease；Emergency treatment；Emergency department, hospital；Risk assessment；Delay time；Definite diagnostic time