A 45-year-old man presented to the emergency department with severe chest pain radiating to his back for 2 hours. His vital signs showed elevated blood pressure and absent radial pulses. An ECG showed sinus tachycardia but no signs of ischemia. A chest x-ray revealed a widened mediastinum. He was initially stabilized and transferred to the CCU for further investigation and management, which may include aortic dissection. Aortic dissection involves a tear in the inner layer of the aorta allowing blood to flow between the layers, and can be classified and treated in different ways depending on its location and severity.

1. CASE SCENARIO:
A 45yrs old man comes to the Emergency department with
severe chest pain radiating to his back. He says that the pain started
suddenly 2 hours ago and is most severe between his shoulder
blades with no remarkable laboratory findings. He has no significant
past medical history. vital signs are : Temp (98.6F),BP = 170/100
mg. Radial pulses are absent bilaterally.ECG demonstrates sinus
tachycardia with a rate of 100/min without any evidence of
ischemia. A Chest X-ray shows widened mediastinum patient was
initially stabilized with betablockers and opioid and shifted to ccu
for further investigation and management.
Can you identify the condition?

9. DEFINITION
Aortic dissection is the tear in the innermost lining of
the arterial wall of aorta that allows blood to enter between
the Intima and media, thus creating a false lumen.

10. INCIDENCE
 Aortic dissection affects 1 per 10,000 person ,
approximately 2000 new cases are reported each year.
 More common in blacks than in whites
 More common in males than females(3:1)

11. ETIOLOGY
 Uncontrolled high blood pressure
 Blunt trauma
 Atherosclerosis
 Aortic coarctation
 Previous heart surgery (aortic valve replacement)
 Genetic disease (Turner’s syndrome ,Marfan’s syndrome,
other connective tissue disorders, Inflammatory or infectious
conditions)

12. HTN
Hypertrophy of Vaso
vasorum
Decreased blood flow to
the aortic wall
Loss/death of smooth
muscle cells in aorta
Weakness of aortic wall
AORTIC DISSECTION
Coarctation of Aorta
Lower left chamber of the
heart works harder to pump
blood through narrowed
aorta
Increases blood pressure
Walls of the blood vessels
get hypertrophy
AORTIC DISSECTION
Connective tissue disorders
(Marfan’s Syndrome)
Autosomal dominant
disorders
Produces weak elastin
tissue(Defect in fibrilin
synthesis )
Dilation of aortic walls
AORTIC DISSECTION

13. RISK FACTORS
 Sex
 Age
 Cocaine use
 Pregnancy
 High intensity weight lifting

14. CLASSIFICATION OF AORTIC DISSECTION
• DeBakey classification
• Stanford classification
• Based on symptom onset
• Based on location
DeBakey Classification groups Aortic Dissection into three
types:
 Type I
 Type II
 Type III (a & b)

15. Type I : Originates in the ascending aorta propagates at least to
the aortic arch.
They are typically seen in patients under 65yrs and
carry the highest mortality.
Type II : Confined to the ascending aorta
Classically in elder patients with atherosclerotic
disease and hypertension.
Type III : Originates from the descending aorta.
Further subdivided into IIIa which extends to the
diaphragm.
IIIb which extends beyond the diaphragm into the
abdominal aorta.

17. STANFORD CLASSIFICATION divides aortic
dissection into two group, A and B.
• Group A : includes DeBakey Types I and Types II
• Group B : includes DeBakey Type III
BASED ON SYMPTOM ONSET
• Acute : within 2 weeks of initial onset of symptoms
• Subacute : within 14-90 days
• Chronic: greater than 90 days (almost type B)
BASED ON LOCATION
• Proximal( Type A)
• Distal (Type B)

18. PATHOPHYSIOLOGY

21. CLINICAL MANIFESTATION
1.Severe chest pain
• Characteristic: Tearing, ripping, shearing sensation
• Mostly 80% occurs in acute type A aortic dissection
• Region: Anterior chest (60%)
Back (55%)
Abdomen (30%)
May extend down to hip and legs
2.Shortness of breath
3.Weakened or absent carotid and temporal pulse
4.Diaphoresis

22. • Decrescendo diastolic blowing murmur
• Weak pulse in one arm or thigh compared with the other
• Difficulty in walking
• Sudden severe abdominal pain
• Neurological deficit
• Loss of vision
• Sudden difficulty in speaking
• Weakness or paralysis of one side of body
• Dizziness
• Syncope

23. DIAGNOSTIC EVALUATION
Detecting an aortic dissection can be tricky because the
symptoms are similar to those of variety of heart problems.
• History collection
• Physical examination
• ECG:
More often ECG demonstrates normal results. One study
has reported normal ECG findings in 63 (90% of 70 patients
with aortic dissection.
Proximal dissection (Type A) shows inferior wall MI

24. • Chest X-ray
Chest X-ray is useful study in patient with
suspected aortic dissection.

26. • Trans Thoracic Echocardiography(TTE)
This test uses high pitched sound waves to
produce an image of the heart.

27. • Computerized Tomography(CT) : windsock sign
(intussusception between true and false lumen)

30. • Magnetic Resonance Imaging (MRI) : Site of Intimal tear,
types and extent of dissection

31. MANAGEMENT
GOAL:
• Stabilize the patient
• Decrease the BP and diminish the shearing force on the aorta
(Target: BP =100-120 mm Hg systolic with HR less than 60
beats)
• Pain management
MEDICAL MANAGEMENT
First Line Drugs : Beta Blockers, Alpha Blockers, Opioid
Analgesics.
Second Line Drugs: Vaso dilators, calcium channel blockers

32. BETA BLOCKERS STARTING DOSE MAINTENANCE
DOSE
Propranolol 1-3mg (IV) 1-3 mg (IV) every 4
hours
Metoprolol 5mg (IV) 5 mg (IV) every 6
hours
Esmolol 500mcg/kg (IV) Continuous IV 50-
300mcg/kg/min
ALPHA AND BETABLOCKERS
Labetalol 20mg (IV),then 40-80 mg
(IV) every 10 min
Continuous IV 1-2
mg/min titrate to
6mg/min
OPIOID ANALGESICS
Morphine 0.1mg/kg (IV) 4-8mg (IV) every 4-6
hours
Hydromorphone 1 mg (IV) 1-4mg (IV) every 3-6
hours
Fentanyl 1-2 mcg/kg (IV) 1-3 mcg/kg/hr
continuous IV infusion

33. VASODILATORS STARTING DOSE MAINTENANCE
DOSE
Sodium Nitroprusside 0.5-3 mcg/kg/min( IV) Continuous (IV )1-3
mcg/kg/min
Nitroglycerin 5mcg/min (IV) Continuous (IV)
5 mcg/min increase
5-20mcg/min
(every 3-5 min)
CALCIUM CHANNEL BLOCKERS
Diltiazem 0.25mg/kg (IV) Continuous (IV)
5-10 mg/hr
Verapamil 2.5-5mg (IV) May repeat 5-10mg (IV)
in 30 min

34. SURGICAL MANAGEMENT
AORTIC DISSECTION
Type A Type B
Open heart complicated uncomplicated
surgery
Endovascular Medical mgt
Dissection Repair
TEVAR

35. Open heart repair or David procedure or Valve
sparing root replacement

37. Thoracic Endovascular Aortic Repair (TEVAR ): is a
minimally invasive treatment for aortic dissection. A
Stent graft is a tube made of a thin metal mesh (stent). It
is covered with a thin polyester fabric (the graft). It is
used to seal the aorta and expand the true lumen in order
to improve the blood flow to other organs.

39. NURSING DIAGNOSIS
• Ineffective tissue perfusion related to compromised
arterial blood flow.
• Decreased cardiac output secondary to progressive
dissection of the aorta
• Acute pain related to decreased myocardial blood flow

40. SUMMARY
A 45yrs old man comes to the Emergency department
with severe chest pain radiating to his back. He says that the
pain started suddenly 2 hours ago and is most severe between
his shoulder blades with no remarkable laboratory findings. He
has no significant past medical history. vital signs are : Temp
(98.6F),BP = 170/100 mg. Radial pulses are absent
bilaterally.ECG demonstrates sinus tachycardia with a rate of
100/min without any evidence of ischemia. A Chest X-ray
shows widened mediastinum patient was initially stabilized
with betablockers and opioid and shifted to ccu for further
investigation and management.

41. REFERENCE

42. JOURNALS
• König, K. C., Lahm, H., Dreßen, M., Doppler, S. A.,
Eichhorn, S., Beck, N., ... & Krane, M. (2021). Aggrecan:
a new biomarker for acute type A aortic
dissection. Scientific Reports, 11(1), 1-12.
https://doi.org/10.1038/s41598-021-89653-y
• Chen, S. W., Chan, Y. H., Chien-Chia Wu, V., Cheng, Y.
T., Chen, D. Y., Lin, C. P., ... & Chou, A. H. (2021).
Effects of fluoroquinolones on outcomes of patients with
aortic dissection or aneurysm. Journal of the American
College of Cardiology, 77(15), 1875-1887.