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Diagnosis of Thoracic Aortic Dissection in the Emergency Department

Guideline by Royal College of Emergency Medicine and Royal College Radiologists – 2025

Thoracic aortic dissection is a rare but time-critical emergency with high mortality if missed. This guideline highlights the diagnostic challenges in the emergency department, emphasising that presentations can be atypical and that normal ECGs, chest X-rays, or blood tests do not reliably exclude the diagnosis. CT aortography is the diagnostic modality of choice and must be rapidly accessible 24/7, with emergency clinicians responsible for requesting and acting on results. The guideline supports the selective use of the Aortic Dissection Detection Risk Score, alongside D-dimer in appropriate patients, and stresses the importance of local protocols for imaging access, escalation, and onward referral once a diagnosis is confirmed

Diagnosis of Thoracic Aortic Dissection in the Emergency Department Guideline (PDF)

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.