5hos2010 june


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5hos2010 june

  1. 1. SHORT CASEkritKuruchaiyapanich R2<br />5 hospital conference : <br />1st<br />@ Rajavithi hospital<br />17 June 2010 <br />
  2. 2. History<br />An elderly Thai female 80 years old<br />Chief complaint: Progressive dyspnea for 2 weeks<br />
  3. 3. History<br />Present illness<br /> - 8 months ago, the patient presented with acute dyspnea .Chest X-ray was shown left pleural effusion size 7*4 cm, trachea in midline, no widening mediastinum. She was diagnosis tapped left pleural effusion. Gross blood was shown.The doctor planned CT Chest for rule out malignancy but she loss follow up.<br />
  4. 4. History (con’t)<br />Present illness<br /> - 2 weeks ago, she was progressive dyspnea on exertion, no chest pain, +ve PND, no orthopnea<br /> no back pain, no fever, no dizziness<br />
  5. 5. History<br />Past illness:<br /> - underlying disease: Ischemic stroke (right hemiparesis) since November 2004 , HT <br /> - medication: ASA(325) 1*1 pc, Enalapril(20)1*2 pc, Zimmex(10) 1*1 hs<br /> - no Hx trauma<br /> - no Hx drugs allergy , no smoking, no alcoholic drinking<br />
  6. 6. Physical examination<br />VS: afebrile, BP 170/123 mmHg, PR 106/min, RR 30/min, O2 sat RA= 95%<br />General appearance: ill-appearing but alert and in no apparent distress<br />Heart: Neck vein engorged,normal S1 and S2 and no murmurs, rubs, or gallops, The peripheral pulses are strong and symmetric in all four extremities.<br />Lungs: decreased breath sound at left lung<br />
  7. 7. Physical examination<br />Abdomen : Soft and non tender,ill-defined palpable mass at epigastrium ,no organomegaly is detected<br />Extremities : No edema or erythema both legs and no deformity, mild pitting edema<br />NS : WNL<br />
  8. 8. Investigation (31/5/2010)<br />
  9. 9. Investigation (31/5/2010)<br />
  10. 10.
  11. 11.
  12. 12. Ultrasound bedside<br />
  13. 13.
  14. 14. Echocardiogram( 7th June 2010)<br />Good LV systolic contraction(EF 80 %), massive pericardial effusion Anterior= 27.2 mm, Posterior= 10.7 mm, no RV collapse, Calcified three cusps of AV with moderate AR(jet area= 45% of LVOT), no AS, normal coaptation of mitral leaflets with no MS, no MR, mild TR with estimated RVSP= 25, no clot can seen<br />
  15. 15. CT Plain<br />
  16. 16.
  17. 17. Result<br />Type B dissecting aneurysm of the descending aorta down to aortic bifurcation with rupture.<br /> Compression of true lumen at level of below left renal a.<br />Aneurysmal dilatation of the ascending aorta with peripheral thrombus.<br />Hemorrhagic pericardial effusion with impending pericardial tamponade.<br />
  18. 18. Diagnosis<br />Type B dissecting aneurysm of the descending aorta with hemorrhagic pericardial effusion<br />
  19. 19. Treatment At ER<br />O2 canula 3 LPM<br />Closed up monitor vital signs<br />Echocardigram searched for cardiac temponade<br />NPO<br />0.9% NaCl 1,000 ml sig IV drip in 40 ml/hr<br />Emergency CT whole aorta<br />
  20. 20. Aortic disection<br />
  21. 21. Epidemiology<br />More often in men and increases with age.<br />Hypertension: most common risk factor.<br />Mortality is 1 - 5 / 100,000 population per year.<br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  22. 22. Classification<br />The Stanford classification<br />Type A dissections involve the ascending aorta<br />Type B dissections do not<br />Distal dissections tend to be older, heavy smokers with chronic lung disease and more often with generalized atherosclerosis and hypertension.<br />acute (< 2 weeks) and chronic (> 2 weeks).<br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  23. 23. Classification<br />
  24. 24. Management<br />Airway, Breathing, Circulation<br />Blood pressure should be measured all four limbs. <br />Patients presenting with hypotension secondary to aortic rupture or pericardial tamponade should be resuscitated with intravenous fluids and immediately transported to the operating room if they are to have a chance to survive. <br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  25. 25. Management<br />The two goals of medical management are to <br /> (1) reduce blood pressure and <br /> (2) decrease the rate of rise of the arterial pulse (dP/dt) to diminish shearing forces<br />Opioids pain control and to decrease sympathetic tone.<br />The use of β-adrenergic blockers is the cornerstone of aortic dissection management target HR is 60-80/ min<br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  26. 26. Management<br />Sodium nitroprusside can be used, in conjunction with a β-blocker, to maintain the systolic blood pressure at 100 to 120 mm Hg or to the lowest level to maintain vital organ perfusion. <br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  27. 27. Surgery<br />Type A acute aortic dissections require prompt surgical treatment.<br />Definitive treatment of type B acute aortic dissections is less clear. Sx for persistent pain, uncontrolled hypertension, occlusion of a major arterial trunk, frank aortic leaking or rupture, or development of localized aneurysm. <br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  28. 28. Prognosis<br /> A “Deadly triad”<br />1. absence of chest pain<br />2. hypotension<br />3. branch vessel involvement<br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  29. 29. Interventional Therapy<br />Stent-graft and fenestration technique for complicated type B dissections<br />Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition<br />
  30. 30. THANK YOU<br />
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