AORTIC DISSECTION

Question 1

MANAGEMENT

Answer 1

STAT CT Angiography of aorta is suspected

Bedside Ultrasound for Pericardial Effusion

Early Emergency Vascular Surgical Consultation

HEMODYNAMIC TARGET:
HR 60-80
SBP < 120 mmHg
Consider Arterial Line
Target based on the extremity with the highest BP

2 DRUG STRATEGY:

Esmolol
500 mcg/kg over 1 minute followed by infusion of 50 mcg / kg / min
Titrate up by 25-50 mcg / kg / min q 15 min to a max of 300 mcg / min

THEN

Nitroprusside 0.5 mcg / kg / min. Titrate up by 0.5 mcg / kg / min to max 10 mcg / kg / min. Max duration 10 min.

OR

Nicardipine 5 mg / hr
titrate up by 2.5 mg/hour every 5-15 minutes to a max of 15 mg/hour

1 DRUG STRATEGY

Labetolol
10 - 20 mg IV over 2 min then q 10 - 15 min until HR is achieved or 300 max
OR
0.5-2 mg/min, titrate up by 0.5 mg/minute every 10 minutes to a max of 10 mg/min.

DISABILITY

Opioid for pain

CALL CARDIO THORACIC SURGERY

INVESTIGATIONS
Type and Screen with Crossmatch

Hgb
Creatinine
LFT’s
Troponin
Lactate
D Dimer

CXR

CTA AORTA r/o Aortic Dissection, Thoracic Aneurysm - Sn & Sp nearly 100%

Question 2

DOCUMENTATION

Risk Factors

Answer 2

SYMPTOMS
95% Pain (typically sudden onset Anterior Chest or Thoracic back )
90% severe / worst / maximal at onset
64% sharp
50% tearing / ripping

Chest pain + 2nd organ system

Abdominal pain
-43% Type B
-22% Type A

FND

Migrating Pain

17% NO Pain:
-80% Type A
-44% ALOC
-25% Syncope
-19% Neuro Deficit

RISK FACTORS
77% HTN
27% Atherosclerosis
16% Aortic Aneurysm
16% Cardiac Surgery
5% Marfan Syndrome

PHYSICAL EXAM

Vitals:
49% HTN
8% Hypotensive

Auscultation:
Diastolic Murmur
-44% Type A

Peripheral Pulses:
-Pulse deficit in 30% Stanford A, 15% Stanford B
Central Pulses

Blood Pressure in both arms:
-BP between both arms of >/20 mm Hg a/w aortic branch arteriers

Neuro Exam:
stroke-like symptoms 4.7%

CXR:
Wide mediastinum
-54% Type A
-43% Type B

AD is a time-dependent disease. Note the key time intervals and interventions:
Time from the onset of symptoms
Time to order, perform, receive, and interpret imaging
Time to order and initiate blood pressure control
Time to receive surgical or radiology consultation
Time to request emergency transfer; time to initiate emergency transfer

Question 3

Complications

Answer 3

Stanford A: acute aortic regurgitation, cardiac tamponade, and myocardial infarction

Question 4

PATHOPHYS

Answer 4

Typical AD

Penetrating Aortic Ulcer

Intramural Hematoma