Background: Chest pain is a common presentation to the Paediatric Emergency Department (PED). It provokes anxiety amongst patients and carers but is seldom associated with significant pathology.Case Presentation Summary: We present the case of an 11-year-old male with a short history of sudden onset chest pain associated with dyspnoea and significant diaphoresis. His only past medical history was asthma; however, it was reported that occasionally he would develop chest pain during competitive sports that would result in him stopping play.On arrival in the PED, he looked extremely unwell and complained of chest pain, worse when supine, as well as feeling “lumps in his neck”. He was hypertensive (BP 130/85), had a respiratory acidosis and an ECG showing a prolonged QT interval (473 ms). He was initially given intravenous opiate analgesia and antiemetics before initial imaging with a chest x-ray. This showed a grossly widened mediastinum with tracheal calibre narrowing at T4-5, concerning for a mediastinal mass.He progressed to a CT chest with contrast, which, most unusually, identified a Type A aortic dissection with a markedly dilated ascending aorta, associated with aortic coarctation distal to the left subclavian artery. He was transferred to cardiothoracic ITU for rapid blood pressure control with IV labetolol, then retrieved to the nearest paediatric cardiac surgical centre for operative management.Learning Points Discussion: Aortic dissection in children remains exceedingly rare, however, it confers significant mortality, with trauma being the leading cause. Currently, no consensus guidelines exist for management in the paediatric population. Clinicians must consider the diagnosis in unwell patients, particularly those with documented hypertension.
