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<\/a><\/p>\nHTN is #1 risk factor<\/p>\n
Marfan’s, ehlers-danlos, bicuspid aortic valve, pregnancy predisposes, Turners, cocaine<\/p>\n
Heart sways from side to side with each beat, aorta is untethered between arch + L subclavian<\/p>\n
May present as syncope, pericardial effusion\/Tamponade, spinal cord ischemia,<\/p>\n
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A small tear forms between the media and adventitia.\u00a0 The outer wall encompassing the dissection is exceedingly thin and prone to rupture.\u00a0 If a second tear forms which allows the blood to reenter the lumen, survival actually increases.\u00a0 If chronic, an aneurysm may form<\/p>\n
The adventitia has a ton of autonomic innervation, this is why patients get sympathetic surge<\/p>\n
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Place radial or L femoral a-line (reserve the right for bypass)<\/p>\n
Lower the heart rate to 60-75, then lower SBP to 100-120\/MAP 60-75<\/p>\n
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Goals of drug therapy<\/p>\n
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Reduce dp\/dt (velocity of LV contraction; rate of rise of aortic pressure) = Reduce Heart Rate,\u00a0 and Inotropy<\/p>\n
Reduce BP<\/p>\n
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I-Ascending and arch<\/p>\n
II-Ascending<\/p>\n
III-descending<\/p>\n
Stanford Classification<\/strong><\/p>\n A-Ascending (surgical)<\/p>\n B-Not ascending (medical)<\/p>\n Almost all have chest or back pain<\/p>\n <\/p>\n Anterior-ascending, jaw or neck-arch, scapular-descending<\/p>\n <\/p>\n Three clinical variables (Arch Int Medicine 2000, 160)<\/p>\n <\/p>\n <\/p>\n <\/p>\n The International Registry of Acute Aortic Dissection published in\u00a0 JAMA does for acute aortic dissection what PIOPED did for pulmonary<\/p>\n embolism: provide clinical insight into an important entity in emergency medicine whose presentation is not always straightforward.<\/p>\n Prompted by advances in imaging and surgical techniques, IRAD enrolled 464 patients with acute dissection.\u00a0\u00a0 Several of the<\/p>\n findings contradict conventional wisdom and must be kept in mind in the ED:<\/p>\n <\/p>\n Patients described the presenting pain more often as sharp<\/p>\n rather than tearing or ripping (64% vs. 51%).\u00a0 Migratory pain has<\/p>\n been described as characteristic but was noted in only 16% of<\/p>\n patients.\u00a0 Pain is at maximum intensity at onset<\/p>\n <\/p>\n Only 15% of patients exhibited a pulse deficit, 19% with type A dissections and 9% with type B<\/p>\n <\/p>\n <\/p>\n Only 62% of patients showed mediastinal widening on the Chest<\/p>\n X-ray.\u00a0 More than one fifth had neither a widened mediastinum nor an<\/p>\n abnormal aortic contour<\/p>\n <\/p>\n <\/p>\n The murmur of aortic regurgitation, said to be found in the<\/p>\n majority of patients in type A dissections due to involvement of the<\/p>\n aortic root was found in only 44% of patients with type A dissection<\/p>\n <\/p>\n <\/p>\n Normal EKG finding have been suggested to be a marker to steer<\/p>\n physicians toward a diagnosis of dissection and away from myocardial<\/p>\n ischemia, usually the major differential diagnosis.\u00a0 Normal EKG<\/p>\n findings were present in less than a third of IRAD patients,<\/p>\n suggesting that this test is not especially helpful in<\/p>\n distinguishing the two.<\/p>\n <\/p>\n Of note, CT scan was the initial imaging modality in 61% of<\/p>\n patients, with echocardiogram (TEE and\/or TTE) used initially in<\/p>\n 33%.\u00a0 Aortography, previously the standard, was used infrequently,<\/p>\n and rarely as the initial study (4%).<\/p>\n Reference:\u00a0\u00a0\u00a0 JAMA 2000; 283: 897-903<\/p>\n <\/p>\n 3 \u00bd % had >20 difference (J Hyperten 20:1089, June 2002) and 18% >10 (Acad Emerg Med 9:342, 2002)<\/p>\n <\/p>\n Physical Exam and C-XR are not sufficient for evaluation (JAMA 287 (17))<\/strong><\/p>\n <\/p>\n Syncope, tamponade, CVA, spinal cord ischemia, pulse discrepancies, aortic regurg<\/p>\n C-XR is abnormal 80-90% of time.\u00a0 Calcification c separation, pleural effusion<\/p>\n Use TEE or CT<\/p>\n Differential-MI, PE, Pericarditis<\/p>\n Treatment<\/p>\n Maintain systolic of 100-120<\/p>\n B-Block to a systolic of 110 first, then if BP still high, add nitroprusside<\/p>\n Labetolol can also be used<\/p>\n Use Trimethaphan camsylate (Arfonad) 1-15 mg\/min, a powerful ganglionic blocker which decreases bp and inotropy, \u00a0if pt can not receive b-blockers.\u00a0 Side effects include orthostatic hypotension, blurred vision, urinary retention, and ileus.<\/p>\n <\/p>\n C-XR Findings (12% have normal X-Ray)<\/p>\n 1.\u00a0\u00a0\u00a0\u00a0\u00a0 Widening of the superior mediastinum<\/p>\n 2.\u00a0\u00a0\u00a0\u00a0 Separation of the calcified intima from the outermost portion of the aorta by more than 5 mm<\/p>\n 3.\u00a0\u00a0\u00a0\u00a0 Loss of aortic knob<\/p>\n 4.\u00a0\u00a0\u00a0\u00a0 Displacement of trachea or NG tube to the right<\/p>\n 5.\u00a0\u00a0\u00a0\u00a0 Downward displacement of the left mainstem bronchus<\/p>\n 6.\u00a0\u00a0\u00a0\u00a0 Disparity in the caliber of the ascending and descending aorta<\/p>\n 7.\u00a0\u00a0\u00a0\u00a0 Apical capping<\/p>\n 8.\u00a0\u00a0\u00a0\u00a0 Pleural effusion (most commonly left sided)<\/p>\n 9.\u00a0\u00a0\u00a0\u00a0 Localized bulge in the aorta<\/p>\n (Eur Heart J D-dimer in ruling out Sodeck G) .1 ug\/cc had 100% sens in a SR and prospective validation; 0.5 ug\/ml would have missed one pt in a pooling of the trials<\/p>\n <\/p>\n another pooled MA showed sens 95% (91-98%)<\/p>\n specificity ranged from 40-100%<\/p>\n <\/p>\n New prospective multicenter in pts with suspected but not proven (220 pts, 87 had dissection) used cutoff 500 ng\/ml. neg LR 0.07 (Circ 2009;119:2702)<\/p>\n <\/p>\n <\/p>\n Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. (Am J Cardiol.<\/a> 2011 Apr 15;107(8):1227-34.)<\/p>\n Plasma DD may thus be used to identify subjects who are unlikely to benefit from further aortic imaging.<\/p>\n <\/p>\n No intimal disruption<\/p>\n <\/p>\n Retrospective study (American J EM 2005;23:439)<\/p>\n 2 deaths in anticoagulated and 2 in non<\/p>\n <\/p>\n Arch Intern Med. 2006 Jul 10;166(13):1350-6. Related Articles, Links Diagnostic Accuracy of Transesophageal Echocardiography, Helical Computed Tomography, and Magnetic Resonance Imaging for Suspected Thoracic Aortic Dissection: Systematic Review and Meta-analysis. Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Department of Anesthesiology, Toho University Ohashi Medical Center, Tokyo, Japan. BACKGROUND: Patients with suspected thoracic aortic dissection require early and accurate diagnosis. Aortography has been replaced by less invasive imaging techniques including transesophageal echocardiography (TEE), helical computed tomography (CT), and magnetic resonance imaging (MRI); however, accuracies have varied from trial to trial, and which imaging technique should be applied to which risk population remains unclear. We systematically reviewed the diagnostic accuracy of these imaging techniques in patients with suspected thoracic aortic dissection. METHODS: Published English-language reports on the diagnosis of thoracic aortic dissection by TEE, helical CT, or MRI were identified from electronic databases. Sensitivity, specificity, and positive and negative likelihood ratios were pooled in a random-effects model. RESULTS: Sixteen studies involving a total of 1139 patients were selected. Pooled sensitivity (98%-100%) and specificity (95%-98%) were comparable between imaging techniques. The pooled positive likelihood ratio appeared to be higher for MRI (positive likelihood ratio, 25.3; 95% confidence interval, 11.1-57.1) than for TEE (14.1; 6.0-33.2) or helical CT (13.9; 4.2-46.0). If a patient had shown a 50% pretest probability of thoracic aortic dissection (high risk), he or she had a 93% to 96% posttest probability of thoracic aortic dissection following a positive result of each imaging test. If a patient had a 5% pretest probability of thoracic aortic dissection (low risk), he or she had a 0.1% to 0.3% posttest probability of thoracic aortic dissection following a negative result of each imaging test. CONCLUSION: All 3 imaging techniques, ie, TEE, helical CT, and MRI, yield clinically equally reliable diagnostic values for confirming or ruling out thoracic aortic dissection.<\/p>\n <\/p>\n abd dissection isolated<\/p>\n Isolated abd dissection (J Vasc Surg 2002;36:205)<\/p>\n <\/p>\n Marfan (50%)<\/p>\n Ehlers-DanlosTurner<\/p>\n Bicuspid aortic valve<\/p>\n Familial aortic dissection (dominantly)<\/p>\n Pregnancy\/puerperium<\/p>\n Catheterization<\/p>\n High blood pressure (both chronic and acute\u0097\u0093sympathetic surge\u0094)<\/p>\n Weight lifting<\/p>\n Cocaine\/crack\/methamphetamine<\/p>\n <\/p>\n <\/p>\n <\/p>\n If you see bifid pulse ox in the right setting, think dissection (Emergency Medicine Journal<\/em> 2009;26<\/strong>:634)<\/p>\n <\/p>\n\n
<\/span>Chest X-Ray<\/span><\/h3>\n
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<\/span>Description of the Pain<\/span><\/h3>\n
<\/span>Pulse Deficit:<\/span><\/h3>\n
<\/span>Mediastinal Widening:<\/span><\/h3>\n
<\/span>Murmur of AR:<\/span><\/h3>\n
<\/span>Electrocardiogram:<\/span><\/h3>\n
<\/span>Interarm Difference<\/span><\/h3>\n
<\/span>D-Dimer<\/span><\/h3>\n
<\/span>Aortic Intramural Hematoma<\/span><\/h3>\n
<\/span>Giving Heparin\/Lytics<\/span><\/h3>\n
<\/a><\/p>\n<\/span>Concominant MI with Aortic Dissection<\/span><\/h2>\n