1.
Aortic dissection

2.
Case presentation50 yo man BIBA at 0230 with 3 hours of dull non-radiating central chest pain.En route, administered O2, 300mg Aspirin, 10mg Morphine and 10mg MetoclopramidePain free on arrival.

3.
Previously wellNo positive risk factors for IHD or PENo regular medication or other drug useNo trauma or recent infections

4.
No prior episodes of chest painVomited twice at home, and described as clammy and pale on arrival of ambulance, with BP 90/60 supine.

5.
On arrivalPaleTemp 37 HR 60BP 60/40mmHg RR 14O2 sat 100% (3L/min)GCS 15/15Equal radial pulses4/6 Systolic murmurLungs clear to auscultation

6.
ECG

7.
Initial treatmentIV fluid 1L Normal saline statColour improved, BP to 90/60 mmHg,Pain freeEarly investigations:Trop T < 3 ng/L (N < 15)

8.
CXR

9.
Course2nd ECG normal and Trop T < 3 at 6 hours post onset of pain2nd litre of saline running, BP still 90/60mm/Hg, HR 60/min, with normal peripheral perfusionBP both arms the sameChest pain “2/10”Decision to order CT angiogram of chest

10.
Intimal tear / flap ofdissection in aortic arch

11.
7.10AM Patient transferred to the OT for repair of the type A dissection and the aneurysmal dilatation of aortic root.

12.
Aortic Dissection

13.
Relatively uncommon (2.6-3.3/100 000 person- years)Initial event in aortic dissection is a tear in the aortic intima.Propagation of the dissection may be 1. Proximal (retrograde) 2. Distal (antegrade)

14.
Complications Aortic valve injury with regurgitation Pericaridal tamponade End organ ischemia, examples include syncope, CVA, mesenteric or renal ischaemia.

15.
Risk factors for aortic dissectionAdvancing ageMale sex 2:1 (Female – pregnancy)Systemic hypertensionPre-existing aortic aneurysmAtherosclerosis

16.
Risk factors for under age 40Collagen vascular disordersVasculitisBicuspid aortic valveAortic coarctationTurners syndromeMarfan syndromePrior aortic valve surgeryInstrumentationTraumaHigh intensity weight lifting or other exerciseCocaine

17.
ClassificationStanfordType A –ascending AortaType B – all other types / sites in aortaDeBakeyType I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally.Type II – Originates / confined to the ascending aorta.Type III – Originates in descending aorta, rarely extends proximally but will extend distally.

18.
DiagnosisRoutine bloods – non diagnostic D-dimer < 500ng/ml unlikely to be dissectionHistory Anterior chest pain in ascending aortic dissection Severe sharp or tearing posterior chest or back pain when the dissection progresses distal to the subclavian artery

19.
Pain can associated withSyncopeStrokeMIHeart failureEnd organ ischemia (splanchnic, renal, extremity or spinal cord ischaemia)Hypertension common with type BHypotension

20.
Diagnosis of aortic dissection dependsupon demonstration of the dissection onimaging studies CXR CT MRI TEE / TTE

21.
 CT

22.
Immediate managementMaintain airway, good supportive careTreat hypotension / hypertension – aim for MAP 60-70 Beta blockers eg esmalol propranolol, labetalol Vasodilators Na nitroprusside Calcium channel blockers eg verapamil, diltiazem

23.
ManagementType A – SurgicalType B – Surgical/medical