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Matters heart armc 7 11-2011

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  • 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.
  • Transcript

    • 1. Matters of the Heart Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, SBCFD, Mercy Air, BFD
    • 2. WHY HOLD THE LASIX?
      • AMR 713 Victorville
      • 85 y/o male SOB x 1 day
        • 3-4 word dyspnea
        • Warm to touch
        • Cough
        • Pedal edema
        • Sats 89% …stach 120…RR 28
    • 3. Acute SOB
      • 66 y/o man presents with acute sob developing over the last 8 hours
      • History of HTN, and tobacco use
      • Diaphoretic, normal mental status
      • Afebrile, HR 110, BP 180/110, RR30, pulse ox. 86%
      • Lungs crackles, JVD, pedal edema
    • 4. Acute SOB
      • What is the optimal treatment in the next 5-10 minutes?
      • A. morphine
      • B. Lasix
      • C. Morphine + lasix
      • D. Ntg + (morphine +- Lasix)
      • E. Nesertide + (morphine + Lasix)
      • F. None of the above
    • 5. Acute SOB
      • What is the optimal treatment in the next 5-10 minutes?
      • A. Nice try :0
      • B. Nope
      • C. Better luck next Time!
      • D. Sounded Good didn ’ t it
      • E. Maybe you consider another career choice
      • F. Ahh YES! None of the above
    • 6. Acute Pulmonary Edema
      • Preload…tries to fill lungs
      • LV Function…emptys heart
      • Afterload…size of hose to empty heart
    • 7. Acute Pulmonary Edema
      • What do you do if the Bathtub is overflowing?
      • Turn off water….Preload
      • Pump it out…LV Function
      • Drain it….Afterload
    • 8. Preload Reduction
      • MS
      • Lasix
      • Nitrates
    • 9. Morphine as Preload Reducer
      • Disadvantges
      • May increase catecholimines
      • Respiratory depression
      • Direct myocardial depressant…decreased SV
      • No good evidence that it is a central preload reducer
    • 10. Trunk Monkey and Dating
    • 11. Morphine Swan Studies
      • Preload increased
      • Worsening cardiac index
    • 12. Lasix
      • Increased catecholine output… activates renin..angiotensin system early on
      • Dieuresis is delayed…at least 90 minutes
      • Decrease stroke volume and cardiac output drop
      • Increases afterload
    • 13. Nitroglyercin
      • Better than morphine or lasix for preload reduction
      • Safer than morphine or lasix
      • Rapid effective iniation of treatment
    • 14. Nitroglyercin How do our treatments Stack up?
      • What do you normally start a Nitro Drip at?
        • 10-40mcg/kg/min
      • How much NTG is in one sl tablet
        • 0.4mg = 400 micrograms nitro
      • How much ntg is in 1 ” nitro Paste
        • 20 micrograms
      • Safer than morphine or lasix
      • Rapid effective iniation of treatment
    • 15. Ace Inhibitors
      • Reduces afterload & some preload benefits
      • Works within 15 minutes
      • Decreases intubation and ICU admission rates
      • Combined ith NTG exceeds benefit of either alone
    • 16. WHY HOLD THE LASIX?
      • Top Articles in 2006
        • Evaluation of Prehospital use of Furosemide in patients with Respiratory Distress
        • Use of Lasix prior to adequate preload and afterload reduction can be harmful
        • Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197
    • 17. WHY HOLD THE LASIX?
        • Lasix given improperly up to 30% of the time
        • Patients that received lasix and/or morphine had increased mortality 2.2 to 22%
        • Use of NTG not associated with worse outcome even if given inappropriately
        • Wuerz (Ann Emerg Med 1992)
    • 18. What about CPAP or BIPAP?
      • Non-Invasive Positive Pressure Ventilation
      • In an Austrialian meta-analysis 23 trials were reviewed
      • They found that when either CPAP or BiPAP were used there was decreased mortality
      • Decreased need for mechanical ventilation
      • Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163
    • 19. Trunk Monkey and ticket advice
    • 20.
      • What am I?
      • Giant cell arteritis is a cause in the young
      • Most patients that have it are old with long-standing hypertension
    • 21. He died from this
    • 22. This is what I Look Like
    • 23.
      • I am seen in up to 44% of patients with Marfan sydrome which represent 5% of all cases of this condition
      • Congential bicuspid aortic valve is seen in about 14% of the cases
    • 24. Answer: Aortic Dissection
      • John Ritter- You might know him as: Jack Tripper from Three's Company ,
      • Born September 17, 1948 in Burbank, CA Died: September 11, 2003 in Burbank, CA
      • Cause of Death: Undetected tear in his aorta
      • (Aortic Dissection)
        • Henry Winkler on John's passing: It is like there is a big tear in the heart of the world.
    • 25. Who Am I?
    • 26. Jonathan Larson
      • American Composer & Playwright
      • Died Jan. 1996
      • The night before the opening of RENT
      He had presented to the ED twice in the week before his death
    • 27.
      • The most effective medication to lower blood pressure in a patient with an aortic dissection is:
        • A. Fentanyl
        • B. Labetalol
        • C. Metoprolol
        • D. Nitroglycerin
        • E. Sodium nitroprusside
    • 28. Answer: E
    • 29.
      • The most specific diagnostic test that can be obtained most rapidly for an emergency department patient to make the diagnosis of aortic dissection is?
        • A. 12 lead ECG
        • B. Aortic angiography
        • C. Helical CT chest scan
        • D. Portable chest x-ray
        • E. Transesophageal echocardiography
    • 30. Answer: C- Helical CT chest scan
    • 31. Imaging Ct with contrast is Ideal (can try without if unstable or renal insuffiency) TEE Angiography No longer gold standard- only looks at changes at Inside lumen…CT is better
    • 32.
      • Chest Pain + Old + HTN
      • Chest Pain + Marfan ’ s
      • Chest Pain + Bicuspid Aortic valve
      • Chest Pain + Tearing / Back Pain
      • Chest Pain + Gi Symptoms
      • Chest Pain + African American
      • Chest Pain + Very Tall
      • Chest Pain + Aortic Regurgitation
      • Chest Pain + Collagen Vascular Disease
      • Chest Trauma
      • Chest Pain + Unequal Pulses
      • =Aortic Dissection
      Always Consider Aortic Dissection
    • 33. Recognizing Aortic Dissection
    • 34. Trunk Monkey pediatrics edition
    • 35. CXR How Sensitive is it?
      • In pooled Data From several recent studies CXR is on 67-70% sensitive for making the diagnosis of Dissection
    • 36. CXR Classic Findings
      • Abnormal Mediastinum
        • Too wide or funny looking
        • L pleural Effusion
        • Calcification of the internal rim of the aorta (5-10mm of soft tissue beyond calcification)
    • 37. CXR Dissection
    • 38. CXR Dissection
    • 39. CXR Dissection
    • 40. EKG
      • Non-discriminatory
      • Rare- but a Aortic dissection that presents with MI most commonly presents with dissection into R coronary will show inferior st elevation
      • Only 1/100 dissections present with STEMI
    • 41. Incidence
      • 5-30 cases per 1 million people
      • Much Less common than ACS but more common the AAA
      • Somewhere between 100 to 1000 Mi ’s for every dissection
      • Mortality increases 1-2% per hour if unrecognized
    • 42. Always Think about the 6 Major causes of Chest Pain Badness!
      • ACS: MI / Angina
      • PE
      • Aortic Dissection
      • Boerhave ’ s (Esophageal Rupture)
      • Tension Pneumothorax
      • Pericardial Tamponade / Myocarditis
    • 43. Risk Factors
      • Male
      • Hypertension
      • Marfan ’ s, Ehler ’ s Danlos
      • Cocaine
      • Pregnancy
      • Polycystic Kidney Disease
      • Increasing Age
      • Turners Syndrome
      • Sleep Apnea
      • Family History
    • 44. Fast Facts About Dissection
      • Difficult DX to make
      • Delay of >24 hours occurred in 31% of proximal Dissection and 53% of distal dissections
      • Frequently delays in dx for some = days
      • Newer studies are showing we may miss >50% of dissections on initial visit
      • Painless dissection: 15% had a painless presentation
      • (Mayo Clin Proc. 2002 Mar;77(3):296. )
    • 45. Fast Facts
      • The most common site of dissection is the first few centimeters of the ascending aorta, with 90% occurring within 10 centimeters of the aortic valve.
      • The second most common site is just distal to the left subclavian artery. Between 5% and 10% of dissections do not have an obvious intimal tear
    • 46. Atypical / Subtle Presentations
      • Abdominal Pain
        • An Aneurysm and dissection may coexist
      • Abdominal pain + Chest Pain
        • Be highly suspicious in pain above and below the diaphragm
      • Isolated neurologic symptoms: altered, seizure, unable to move legs
      • Chest Pain and Leg pain
    • 47. D-dime r to r/o dissection?
      • No well defined cut off
      • Cut off for PE 500ng/dl 98% at 500
      • For Dissection 100ng/dl sensitivity 100% r/o for dissection
      • Does not r/o intramural hematoma
    • 48. Atypical / Subtle Presentations
      • Paralysis
        • No pain and presents like spinal cord injury
        • Compromise of spinal artery
      • Syncope- IRAD Study (JAMA 2000;283:897-903)
        • 13% of patients with aortic dissection had syncope as their only symptom
        • Many with no CP/back pain/abdominal pain
    • 49. Myth
      • ALL Patients with Aortic
      • Dissection Look Ill
    • 50. 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
    • 51.  
    • 52.
      • There is a tear (arrow) located 7 cm above the aortic valve and proximal to the great vessels in this aorta with marked atherosclerosis. This is an aortic dissection.
    • 53. Trunk Monkey chasing bad eggs
    • 54.
      • 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.
    • 55.
      • Stanford Type A / DeBakey Type II
      Classification
    • 56.
      • Stanford Type B / DeBakey III
      Classification
    • 57. Classification of Aortic Dissection
      • Classic with true and false lumens separated by intimal flap
      • Medial disruption with intramural hematoma or hemorrhage
      • Discrete/subtle aortic dissection bulge at tear site with no hematoma
      • Plaque rupture/penetrating aortic ulcer
      • Iatrogenic and traumatic dissection
      • Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81
    • 58. Class 1: Classic dissection
    • 59. Aortic Dissection
    • 60.    Intramural Hematoma
      • 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 .
    • 61. Intramural Hematoma
    • 62. Class 2: Intramural hematoma
    • 63. Initial Medical Therapy
      • Pain control: opiates
      • Heart Rate control: Labetalol (bolus & maintenance) vs Titrate- Esmolol
      • Heart Rate < 70
      • BP control: Nipride (Target SBP< 110, DBP<70)
      • Monitor hemodynamics, pulses
    • 64. Trunk Monkey delivers first aid
    • 65. 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
    • 66. Initial Treatment of Type B Dissection
      • Initial treatment: hypotensive medication
      • Reserve intervention for 30-40% with:
        • Rupture
        • End-organ ischemia / malperfusion
        • Localized false aneurysm
        • Refractory hypertension
        • Continuing pain
    • 67. Initial Treatment of Type B Dissection
      • Initial treatment: hypotensive medication
      • Reserve intervention for 30-40% with:
        • Rupture
        • End-organ ischemia / malperfusion
        • Localized false aneurysm
        • Refractory hypertension
        • Continuing pain
    • 68. Mechanisms Involved in Aortic Dissection Type B
      • Primary tear: usually close to the aortic isthmus
      • End-organ ischemia:
        • Static obstruction from extension of dissection into side branches
        • Dynamic obstruction from the intimal flap bowing into the true lumen
        • Combination of static and dynamic obstruction
    • 69. Prognosis
      • Poor-1/3 of patients with h/o dissection will re-dissect, rupture or extend their dissection in the next 5 years
    • 70. Trunk Monkey encounters aliens
    • 71. THANK YOU
      • Questions?
      • You can contact me at:
      • [email_address]
      • 1-951-544-5433