Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
Figure 2a. (a) Schematic of aortic layers in typical aortic dissection shows a tear of the intimal layer, which has resulted in the formation of two lumina (one false, one true). (b) Photograph of an autopsy specimen shows a Stanford type B aortic dissection. An intimal tear (arrows) and intimal calcifications (arrowheads) are clearly visible in the descending aorta.
Figure 10a. (a) Schematic of aortic layers in IMH shows a hemorrhage within the media but no intimal tear. Red dots inside the media represent the vasa vasorum. (b) Photograph of an autopsy specimen reveals hematoma (*) within the media, between the intima (held in place by a surgical clamp) and the adventitia (arrow). There is no evidence of intimal tear.
Matters of the Heart Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, SBCFD, Mercy Air, BFD
34 year old construction worker with sudden onset back pain - discharged home with motrin Tall 28 year old with Chest Pain as he is being discharged the attending happens to ask have you had any surgery before… prior eye surgery
This aorta has been opened longitudinally to reveal an area of fairly limited dissection that is organizing. The red-brown thrombus can be seen in on both sides of the section as it extends around the aorta. The intimal tear would have been at the left. This creates a "double lumen" to the aorta. This aorta shows severe atherosclerosis which, along with cystic medial necrosis and hypertension, is a risk factor for dissection.
In contrast to typical aortic dissection, in which there is an intimal tear , IMH is caused by a spontaneous hemorrhage of the vasa vasorum of the medial layer , which weakens the media without an intimal tear.
Clinical manifestations and the risk factors in IMH are similar to those in typical aortic dissection. IMH accounts for approximately 13% of the prevalence of acute aortic dissection .
Intial Treatment Type A Urgent surgical intervention is required in type A dissections The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased Dissections involving the arch are more complicated that those involving only the ascending aorta because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10% Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future