What caused this patient's chest pain and refractory hypotension?
According to his son, the patient had complained of chest and back pain the previous day. The patient is an ex-smoker and has a long-standing history of chronic obstructive pulmonary disease (COPD) and poorly controlled hypertension. He lives alone. His family history is positive for hypertension and heart disease.
In the ED, physical examination revealed an intubated, unresponsive patient with a Glasgow Coma Scale score of 3 out of 15, and persistent hypotension (systolic BP of 80 to 90 mm Hg despite vasopressors). He has present but feeble brachial and radial pulses; femoral and pedal pulses cannot be palpated bilaterally. His skin is diffusely mottled and cool to touch. An ECG and chest radiograph were taken emergently (Figure 1).