A 66 year old man has had for threehours terrible “sharp-tearing”intrascapular back pain. At the time ofonset, he was lift...
A 72 year old female has over thepast 3 hours had severe aching leftarm pain.Exam: 144/76, 68, 36.4, 22Ashen left upper ex...
AORTICEMERGENCIES   Wayne Triner DO MPH FACEP               Wanganui District Health Board               State University ...
The Normal Aorta From Aortic Annulus to Bifurcation   Ascending   Arch   Descending Diameter 3cm to 2 cm. Numerous Ostea I...
Thoracic Dissection 2.5 to 5 / 100,000   1/3 may go undiagnosed Risk Factors   Hypertension   Age   Marfan’s   Crack
Pathogenesis of DissectionSeparation of layers within the media  Initiating Event    Intimal Tears  Progression of  Dissec...
Dissection Anatomy                 Location of Tear                     60% Convexity of                     Sinus        ...
Natural Course Ascending                  Descending (70% of all dissections)                              70% chronicity ...
Diagnosis History   90% have pain Physical Exam   Hypertension   Shock   Aortic Regurg   Branch Vessel   Occlusion d-dimer
CXR Findings of DissectionWide MediastinumIncreased Aortic WallThicknessLeft Pleural EffusionMass Effect  trachea  NG tube...
Thoracic Aortic CT Angiogram
TEE      *
Medical ManagementSheer Forces dp/dt            dp        dp       dt        dt
Medical Management Analgesia Esmolol Nitroprusside LabatololStart in critical care setting (ED). If going to  maintain on ...
ManagementDecisions Time to Diagnosis Medical or Surgical  Based upon  classification   – A or B  Progression or  impendin...
TEVAR
A 63 year old male presents with sharp left flankand testicular pain of progressing severity over2 days. There has been no...
“Stone Protocol” CT
Who, When Caucasian males      Prevelance between 2% > 60 yo              and 8% of men > 60 yo Family Hx            More ...
ED Bedside Ultrasound Immediately available In “definitive” exams*   Sens > 95%   Spec > 95% Generally < 4 minutes
A 62 year old male presents with severe sharp low back and flank pain of two hours duration with associated nausea and vom...
Misdiagnosis Most common misdiagnosis of AAA?  Terrible sharp back pain  Writhing on bed  60 year old male
AAA Repair
EndoVascularInfra-renal              Aortic Repair              (EVAR)
Post Operative Complications ofAAA RepairEarly                   Late  Everything bad          Open        Renal injury   ...
Endograft Complications
85 yo female fell striking back.X-ray obtained for lumbar tenderness.   A) Notify the OR and                              ...
At the End of the Day Basic Awareness Institutional Awareness Supportive Strategies Careful Planning
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
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Aortic emergencies

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  • Pros 99% Sensitive Allows Operative Planning Fast Minimally Invasive Allows On-going Resuscitation Cons Misses Branch Vessels Requires Expertise May Miss Proximal Arch
  • Location: anywhere along the GI tract, most commonly the duodenum Very high mortality (60%) bleeding sepsis co-morbidity Dx: Clinical suspicion Clinical suspicion Clinical suspicion endoscopy angio CT (periaortic fluid)
  • Aortic emergencies

    1. 1. A 66 year old man has had for threehours terrible “sharp-tearing”intrascapular back pain. At the time ofonset, he was lifting a heavy box. PMH; CAD,HTNBP 210/134 HR 118 RR 28 T 98.6He is in severe distress2/6 diastolic murmur
    2. 2. A 72 year old female has over thepast 3 hours had severe aching leftarm pain.Exam: 144/76, 68, 36.4, 22Ashen left upper extremity with nopulsesRemainder of exam is normal A 62 year old male has the abrupt onset of urinary incontinence and weakness of both legs. He has had three days of thoraco-lumbar back pain. Exam: 184/98, 68, 36.8, 18 Normal other than flaccid and insensate lower extremities.
    3. 3. AORTICEMERGENCIES Wayne Triner DO MPH FACEP Wanganui District Health Board State University of New York Albany Medical College
    4. 4. The Normal Aorta From Aortic Annulus to Bifurcation Ascending Arch Descending Diameter 3cm to 2 cm. Numerous Ostea Intima, Media, Adventitia, Pericardium
    5. 5. Thoracic Dissection 2.5 to 5 / 100,000 1/3 may go undiagnosed Risk Factors Hypertension Age Marfan’s Crack
    6. 6. Pathogenesis of DissectionSeparation of layers within the media Initiating Event Intimal Tears Progression of Dissection Sheer forces
    7. 7. Dissection Anatomy Location of Tear 60% Convexity of Sinus 10% Arch 30% descending Aorta
    8. 8. Natural Course Ascending Descending (70% of all dissections) 70% chronicity 90% 72 hr mortality 10% operative (1-2%/hour) mortality 50% Aortic Regurg 10% medical 15% operative mortality mortality
    9. 9. Diagnosis History 90% have pain Physical Exam Hypertension Shock Aortic Regurg Branch Vessel Occlusion d-dimer
    10. 10. CXR Findings of DissectionWide MediastinumIncreased Aortic WallThicknessLeft Pleural EffusionMass Effect trachea NG tube left mainstem bronchus15% will have noabnormality
    11. 11. Thoracic Aortic CT Angiogram
    12. 12. TEE *
    13. 13. Medical ManagementSheer Forces dp/dt dp dp dt dt
    14. 14. Medical Management Analgesia Esmolol Nitroprusside LabatololStart in critical care setting (ED). If going to maintain on medical therapy, transition to oral within 24 hours of adequate control
    15. 15. ManagementDecisions Time to Diagnosis Medical or Surgical Based upon classification – A or B Progression or impending rupture Branch vessel occlusion
    16. 16. TEVAR
    17. 17. A 63 year old male presents with sharp left flankand testicular pain of progressing severity over2 days. There has been no trauma, urethraldischarge, fever or scrotal swelling.BP 186/102, HR 108, RR 20, T98.2Abd: obese, mildly tender GU: non-tender, non-enlarged testicles normal scrotum, normal penis without dischargeU/A: 1+ HEMATURIA
    18. 18. “Stone Protocol” CT
    19. 19. Who, When Caucasian males Prevelance between 2% > 60 yo and 8% of men > 60 yo Family Hx More common in Maori Smokers (8.9 vs 3.7 per 100,000) ~ 15,000 US deaths from HTN rupture The Law of LaPlace 50% of ruptured AAAs survive to hospital 50% mortality for those reaching hospital
    20. 20. ED Bedside Ultrasound Immediately available In “definitive” exams* Sens > 95% Spec > 95% Generally < 4 minutes
    21. 21. A 62 year old male presents with severe sharp low back and flank pain of two hours duration with associated nausea and vomiting.BP 90/P, HR 124, RR 32, T 96.6pale, cool, diaphoretic, severe distressLungs CTA, HSRRRABD: pulsatile, tender large mass
    22. 22. Misdiagnosis Most common misdiagnosis of AAA? Terrible sharp back pain Writhing on bed 60 year old male
    23. 23. AAA Repair
    24. 24. EndoVascularInfra-renal Aortic Repair (EVAR)
    25. 25. Post Operative Complications ofAAA RepairEarly Late Everything bad Open Renal injury Aortoenteric Cord injury Fistula – Herald bleed Peri-op MI Distal emboli Graft Infection EVAR Endoleak Migration *
    26. 26. Endograft Complications
    27. 27. 85 yo female fell striking back.X-ray obtained for lumbar tenderness. A) Notify the OR and get a surgeon. B) Obtain an emergent uncontrasted CT. C) Have her seen in vascular clinic the next day. D) Give her an enema.
    28. 28. At the End of the Day Basic Awareness Institutional Awareness Supportive Strategies Careful Planning

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