A middle-aged man with no significant medical history presented to ED with sudden onset severe chest pain radiating to his back. He was eating when pain began. Pain was intensifying so he called EMS. He received 324 mg ASA and 0.4 mg nitroglycerin prior to ED arrival. On arrival BP was 140/55, HR 74. In triage he was profusely diaphoretic and ill-appearing and so was brought to the resuscitation room. Lungs were clear to auscultation. While he had a 2+ pulse in the right upper extremity, the team was unable to palpate a pulse in his left upper extremity. He had no acute ischemia on EKG. He had a large bore IV placed and was brought immediately for a CTA.
