Aortic dissection

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Aortic dissection

  1. 1. Aortic Dissection Christie Herr, PGY-IV Emergency Medicine
  2. 3. Pathophysiology <ul><li>Disruption of intima of aortic wall, blood dissects into media, creating false lumen </li></ul><ul><li>Dissection can propagate down/up the aorta through false lumen </li></ul><ul><li>May empty back into true lumen of aorta, or rupture through adventitia </li></ul>
  3. 4. Risk factors <ul><li>Uncontrolled Hypertension </li></ul><ul><li>Advancing age </li></ul><ul><li>Connective tissue disease (Marfan’s, Ehler’s Danlos) </li></ul><ul><li>Congenital heart disease (Bicuspid aortic valve) </li></ul><ul><li>Giant cell arteritis </li></ul><ul><li>Family history </li></ul><ul><li>Stimulant use </li></ul>
  4. 5. Classifications <ul><li>DeBakey </li></ul><ul><ul><li>Type I= ascending aorta, aortic arch, descending aorta </li></ul></ul><ul><ul><li>Type II= ascending aorta only </li></ul></ul><ul><ul><li>Type III= descending aorta distal to left subclavian artery </li></ul></ul><ul><li>Stanford (most common) </li></ul><ul><li>* Type A = involves ascending aorta </li></ul><ul><li>* Type B = no ascending aorta, distal </li></ul>
  5. 7. Symptoms <ul><li>Severe chest, neck , or back </li></ul><ul><li>Can be ripping, tearing, but commonly sharp </li></ul><ul><li>Abrupt and maximal in onset </li></ul><ul><li>Nausea, vomiting, diaphoresis </li></ul><ul><li>Syncope (5-10%) </li></ul><ul><li>Neurologic symptoms (5%), if carotid or spinal artery involved </li></ul>
  6. 8. Exam <ul><li>Can be normal </li></ul><ul><li>Hypertension (normal or low doesn’t exclude dissection) </li></ul><ul><li>If subclavian artery involved= asymmetric pulses or BP (>20 mm of Hg BP difference between arms) </li></ul><ul><li>If proximal dissection </li></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>New murmur of aortic regurg ± CHF </li></ul></ul>
  7. 9. Differential Diagnosis <ul><li>ACS </li></ul><ul><li>PE </li></ul><ul><li>PTX </li></ul><ul><li>Ruptured aneurysm </li></ul><ul><li>Esophageal perforation </li></ul>
  8. 10. Diagnosis <ul><li>CXR= widened mediastinum, loss of aortic knob, pleural capping </li></ul><ul><li>Ultrasound= tamponade in unstable patient </li></ul><ul><li>CT Angio= high sensitivity & specificity </li></ul><ul><li>Aortography= classic “gold standard”, but largely replaced by CT Angio </li></ul>
  9. 11. Treatment <ul><li>GOAL = decrease shearing forces by reducing BP and the rate of rise of the arterial pulse </li></ul><ul><li>If hypotensive= IVF, pressors, pericardiocentesis if tamponade </li></ul><ul><li>If SBP >120= IV B-blockers ( Esmolol or Labetalol drip), add IV nitroprusside if needed, goal systolic BP 100-120, goal HR is 60-80 </li></ul>
  10. 12. Treatment <ul><li>Stanford Type A= surgical repair </li></ul><ul><li>Stanford Type B= </li></ul><ul><ul><li>Medical management </li></ul></ul><ul><ul><li>Surgery for distal dissections if leaking, ruptured, or compromising blood flow to vital organ </li></ul></ul><ul><ul><li>Inability to control HTN with meds also indication for surgery </li></ul></ul><ul><ul><li>Marfan syndrome requires surgery </li></ul></ul>

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