Red Book - Aortic Dissection

Question 1

Classify Dissections

Answer 1

Stanford

DeBakey

European Society of Cardiology

Question 2

Describe the Stanford

Answer 2

Types A and B

A - involves ascending aorta

B - descending only distal to origin of left subclavian artery

Question 3

Describe DeBakey

Answer 3

I - ascending and propogates to the aortic arch

ii - acending only

iii - originates in descending
iiia - limited to thoracic aorta
iiib - extends below diaphragm

Question 4

Risk factors for dissection

Answer 4

Advanced Age
Hypertension
Male
Smoker
Family history
Pregnancy
Trauma (decel injury)
Congenital (Marfans, Ehlers, co-arctation, Turners)

Question 5

Features of a dissection

Answer 5

A - sudden onset chest pain extending into the back
B - back pain alone

Differential/Absent pulses or delays in the extremities

Aortic regurg

Syncope - impaired cerebral flow
Stroke or other neurology

Question 6

Complications of a dissection

Answer 6

CVS - Myocardial ischaemia
           Tampanade
            Acute aortic regurg
            Hypertension
            Hypotension/shock  (due to tampondae or blood loss or coronary dissection)

Neuro - ischaemic stroke
paraplegia - spinal cord hypoperfusion

Pulm - effusions (left)

Renal (AKI)

Haem - Coagulopathy and transfusion need

GI - mesenteric ischaemia

Question 7

Types of imaging

Answer 7

CXR - wide mediastinum
effusion - cardiomegaly
calcified aortic knuckle

TTE - may see intimal flap, aortic regurg, assess cardiac function

TOE - identify true and false lumens

CT - extent of flap, enable surgical plan

MRI - confirms and reveals extent

Aortography - not done but was gold standard (needs contrast, takes a long time)

Question 8

Principles of management

Answer 8

ABCDE etc.

Goals
Treat hypertension
Confirm dissection
Establish need for surgery

i. initial actions
O2
large bore cannular, FBC, U&E, Clotting, xmatch 6 units, venous gas, trop)
Art line
Catheter
ECG
Analgesia
Manage hypotension - volume aiming for systolic of 100mmh
Find aeotiology, involve surgeons

Question 9

Hypertension management in dissection

Answer 9

Low SBP to 100-120 MAP 60-65

Reduce shear force but no reflex tachy (b-blockers - esmolol/labet)
Vasodilators GTN, SNP

2nd line - CCB