Aortic dissection resident survival guide: Difference between revisions

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==Overview==
==Overview==
[[Aortic dissection]] (AD) is a disruption of the medial layer of the [[aorta]] triggered by intramural bleeding. It is commonly due to an intimal tear that causes tracking of blood in a dissection plane within the media. Blood accumulation results in a separation of the aortic wall layers with ensuing formation of a true lumen and a false lumen with or without communication between the two.  Aortic dissection is a medical emergency and can quickly lead to death if not managed urgently.  Patients classically present with abrupt onset of severe, knife-like [[chest pain|chest]] (most common), back, or abdominal pain. Other important features that increases the probability of aortic dissection include pulse deficits, systolic blood pressure differences between limbs, focal neurologic deficits, new aortic murmurs, shock, and a history of connective tissue disease and aortic valve disease. CT, MRI, or transesophageal echocardiography (TEE) may be used for the diagnosis AD, although CT is preferred because of it's speed, excellent sensitivity, and superiority in diagnosing arch vessel involvement. Serial imaging is recommended to monitor for progression of the dissection. After excluding possible aortic regurgitation, intravenous beta-blockers should be initiated in all patients to reduce the systolic blood pressure (SBP) to 100 to 120 mmHg and controlling the heart rate, to minimize the shear stress on the aortic wall. Treatment depends on the anatomic location of the dissection and complications. Uncomplicated [[Aortic dissection resident survival guide#Classification|type B]] dissections should be treated medically whereas [[Aortic dissection resident survival guide#Classification|type A]] dissections and complicated [[Aortic dissection resident survival guide#Classification|type B]] dissections should be treated surgically. Complications of AD include aortic regurgitation, myocardial ischaemia or infarction, pleural effusion, stroke, mesenteric ischemia, and acute kidney injury.<ref name="pmid25173340">{{cite journal| author=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H et al.| title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2014 | volume= 35 | issue= 41 | pages= 2873-926 | pmid=25173340 | doi=10.1093/eurheartj/ehu281 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25173340  }} </ref>
[[Aortic dissection]] (AD) is a disruption of the medial layer of the [[aorta]] triggered by intramural bleeding. It is commonly due to an intimal tear that causes tracking of blood in a dissection plane within the media. Blood accumulation results in a separation of the aortic wall layers with ensuing formation of a true lumen and a false lumen with or without communication between the two.  Aortic dissection is a medical emergency and can quickly lead to death if not treated urgently.  Patients classically present with abrupt onset of severe, knife-like [[chest pain|chest]] (most common), back, or abdominal pain. Other important features that increases the probability of aortic dissection include pulse deficits, systolic blood pressure differences between limbs, focal neurologic deficits, new aortic murmurs, shock, and a history of connective tissue disease and aortic valve disease. CT, MRI, or transesophageal echocardiography (TEE) may be used for the diagnosis AD, although CT is preferred because of it's speed, excellent sensitivity, and superiority in diagnosing arch vessel involvement. Serial imaging is recommended to monitor for progression of the dissection. After excluding possible aortic regurgitation, intravenous beta-blockers should be initiated in all patients to reduce the systolic blood pressure (SBP) to 100 to 120 mmHg and controlling the heart rate, to minimize the shear stress on the aortic wall. Treatment depends on the anatomic location of the dissection and complications. Uncomplicated [[Aortic dissection resident survival guide#Classification|type B]] dissections should be treated medically whereas [[Aortic dissection resident survival guide#Classification|type A]] dissections and complicated [[Aortic dissection resident survival guide#Classification|type B]] dissections should be treated surgically. Complications of AD include aortic regurgitation, myocardial ischaemia or infarction, pleural effusion, stroke, mesenteric ischemia, and acute kidney injury.<ref name="pmid25173340">{{cite journal| author=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H et al.| title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2014 | volume= 35 | issue= 41 | pages= 2873-926 | pmid=25173340 | doi=10.1093/eurheartj/ehu281 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25173340  }} </ref>


==Classification==
==Classification==
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===Common Causes===
===Common Causes===
*[[Hypertension]] (underlying cause in 70%)
*[[Hypertension]] (underlying cause in 70% of cases)
*Pre-existing aortic diseases or aortic valve disease
*Pre-existing aortic diseases or aortic valve disease
*Blunt chest [[trauma]]
*Blunt chest [[trauma]]
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:❑ [[chest pain|Tearing]] or [[chest pain|sharp]] in quality <br>
:❑ [[chest pain|Tearing]] or [[chest pain|sharp]] in quality <br>
:❑ Increasing in intensity <br>
:❑ Increasing in intensity <br>
''Associated with any of the following:''<Br>
❑ Unexplained [[syncope]]<br>
❑ Unexplained [[syncope]]<br>
❑ Focal neurological deficits<br>
❑ Focal neurological deficits<br>
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{{familytree  | | | | | | | |!| | | | | | | | |}}
{{familytree  | | | | | | | |!| | | | | | | | |}}
{{familytree  | | | | | | | B01 | | | | | | | |B01=<div style="text-align:center; padding:0.7em">'''Does the patient have the following findings which require urgent management?'''</div><div style="text-align:left; padding:0.7em">
{{familytree  | | | | | | | B01 | | | | | | | |B01=<div style="text-align:center; padding:0.7em">'''Does the patient have the following findings which require urgent management?'''</div><div style="text-align:left; padding:0.7em">
❑ Hemodynamic instability:
:❑ Hypotension or shock<br>
:❑ [[Hypotension]]<br>
:❑ Perfusion deficits <br>
:❑ [[Cold extremities]]<br>
</div>}}
:❑ [[Peripheral cyanosis]]<br>
:❑ [[Mottling]]<br>
:❑ [[Altered mental status]]<br>
:❑ [[Oliguria]]
❑ High risk features<br>
<SMALL>Presence of 2 or more high risk features, requires immediate surgical management.</SMALL><br>
:❑ [[Unequal pulses|Difference in the blood pressure in both extremities]] <br>
:❑ Signs of [[shock]] ([[hypoperfusion]]) <br>
:❑ [[Pulse]] deficit involving [[Common carotid artery|carotid]], [[Femoral artery|femoral]] or [[subclavian arteries]] <br>
:❑ [[Diastolic murmur]] suggestive of [[aortic regurgitation]] <br>
:❑ [[Marfan's syndrome]] <br>
:❑ Signs suggestive of [[stroke]]
:❑ Aortic disorder <br>
:❑ [[Aortic valve disease]] <br>
:❑ Recent aortic manipulation <br></div>}}
{{familytree  | | | | | | | |!| | | | | | | }}
{{familytree  | | | | | | | |!| | | | | | | }}
{{familytree  | | | | |,|-|-|^|-|-|.| | }}
{{familytree  | | | | | |,|-|^|-|-|.| | }}
{{familytree  | | | | C01 | | | | C02 | C01='''Yes'''|C02='''No'''}}
{{familytree  | | | | |C01 | | | C02 | C01={{fontcolor|#F8F8FF|'''Yes'''}}|C02='''No'''|boxstyle_C01= background-color: #FA8072}}
{{familytree  | | | | |!| | | | | |!| | }}
{{familytree  | | | | | |!| | | | |!| | }}
{{familytree  | | | |DAA  | | | | DBB | | DAA=<div style="background: #FA8072; text-align: left; ; padding:0.7em"> {{fontcolor|#F8F8FF|'''Assess the following things simultaneously'''<br>
{{familytree  | | | | |DAA  | | | DBB | | DAA=<div style=" background: #FA8072; text-align: center; width:27em; padding:0.7em"> {{fontcolor|#F8F8FF|'''Attempt to stabilize patient'''}}</div> <div style=" background: #FA8072; text-align: left; padding:0.7em"> {{fontcolor|#F8F8FF|❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Assess hemodynamic stability <br>
:❑ Consider intubation if the patient's airway is compromised, has a glasgow coma scale (GCS < 8) or profound haemodynamic instability
❑ Order urgent [[TEE|<span style="color:white;">TEE</span>]] and look for the following features: <br>
:❑ Administer oxygen and maintain a saturation >90%
:❑ [[Pericardial effusion|<span style="color:white;">Pericardial effusion</span>]] <br>
:❑ Secure 2 large-bore intravenous lines (IVs) and initiate fluid resuscitation
:❑ Regional wall motion abnormality (RWMA) <br>
:❑ Titrate fluids to a mean arterial blood pressure of 70 mm Hg, overzealous fluid administration may lead to progression of the dissection
:❑ Dilated root <br>
:❑ Consider vasopressors only if patient remains hypotensive despite fluids
:❑ [[Aortic regurgitation|<span style="color:white;">Aortic regurgitation</span>]] (AR)}} </div><br>
❑ Obtain 12 lead ECG and place the patient on a cardiac monitor<br>
|DBB=<div style=" text-align: center; padding:0.7em">'''[[Aortic dissection resident survival guide#Complete Diagnostic Approach|Continue with the diagnostic approach below]]'''</div>
❑ Consider intra-arterial [[BP|<span style="color:white;">BP</span>]] monitoring<br>
|boxstyle_DAA= background-color: #FA8072;
❑ Place an indwelling urethral catheter and monitor urine output <br>
}}
❑ Frequently assess [[altered mental status|<span style="color:white;">mental status</span>]] and check for focal neurologic deficits<br>
{{familytree  | | | | |!| | | | | | | | | | | | }}
❑ Monitor development or progression of [[Carotid bruit|<span style="color:white;">carotid</span>]], [[Bruit|<span style="color:white;">brachial</span>]], or [[Bruit|<span style="color:white;">femoral bruits</span>]]<br>
{{familytree  | | | | E01 | | | | | | | | | | E01=<div style=" background: #FA8072;"> {{fontcolor|#F8F8FF|'''Does the patient have [[hypotension|<span style="color:white;">hypotension</span>]]'''}}</div>|boxstyle = background-color: #FA8072;}}
❑ Type and crossmatch patient for possible blood transfusion
{{familytree  | | |,|-|^|-|.| | | | | | | | | }}
❑ Obtain blood for [[CBC|<span style="color:white;">CBC</span>]], electrolytes, BUN, creatinine, LFTS, and [[Cardiac enzymes|<span style="color:white;">troponin I, and CK-MB</span>]] <br>}}</div>
{{familytree  | | F01 | | F02 | | | | | | | | | | F01=<div style=" background: #FA8072;"> {{fontcolor|#F8F8FF|'''Yes'''}}</div>|F02=<div style=" background: #FA8072;"> {{fontcolor|#F8F8FF|'''No'''}}</div>|boxstyle = background-color: #FA8072;}}
----
{{familytree  | | |!| | | |!| | | | | | | | | }}
<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Control blood pressure'''}}</div><div style=" background: #FA8072; text-align: left; padding:0.7em"> {{fontcolor|#F8F8FF|❑ Beta blockers are first-line agents, as they circumvent the [[reflex tachycardia|<span style="color:white;">reflex tachycardia</span>]] associated with blood pressure lowering<br>
{{familytree  | | G01 | | G02 | | | | | | | | | | G01= <div style=" background: #FA8072; text-align: left; padding:0.7em"> {{fontcolor|#F8F8FF|
::❑ '''[[Esmolol|<span style="color:white;">Esmolol</span>]]'''
❑ Assess airway, breathing, and circulation <br>
:::❑ 500 micrograms/kg intravenous push initially, followed by 50 micrograms/kg/min for 4 min
❑ Place a cardiac monitor to monitor cardiac rhythm <br>
:::❑ If necessary increase infusion up to 200 micrograms/kg/min<br>
Intra-arterial [[BP|<span style="color:white;">BP</span>]] monitoring<br>
::'''OR'''
Secure 2 large-bore intravenous lines (IVs) <br>
::❑ '''[[Metoprolol|<span style="color:white;">Metoprolol</span>]]'''
❑ Monitor [[oxygen|<span style="color:white;">oxygen</span>]], respiration, [[blood pressure|<span style="color:white;">blood pressure</span>]], and urine output <br>
:::5 mg intravenously every 5-10 minutes
❑ Frequently assess, [[shock|<span style="color:white;">hemodynamic compromise</span>]], [[altered mental status|<span style="color:white;">mental status changes</span>]], [[neurologic|<span style="color:white;">neurologic</span>]] or [[Peripheral vascular disease|<span style="color:white;">peripheral vascular changes</span>]]<br>
:::❑ If necessary increase up to a maximum dosage of 15 mg/total dose
Monitor development or progression of [[Carotid bruit|<span style="color:white;">carotid</span>]], [[Bruit|<span style="color:white;">brachial</span>]], and [[Bruit|<span style="color:white;">femoral bruits</span>]]<br>
::'''OR'''
Indwelling urethral catheter is used to monitor urine output<br>
:: '''[[Labetolol|<span style="color:white;">Labetalol</span>]]'''
❑ Obtain blood samples for,<br>
:::❑ 1-5 mg/min IV infusion<br>
:❑ [[CBC|<span style="color:white;">CBC</span>]], electrolytes <br>
::'''OR'''
:❑ [[Cardiac enzymes|<span style="color:white;">Cardiac enzymes</span>]] to rule out [[MI|<span style="color:white;">MI</span>]] <br>
❑ Substitute with [[Non-dihydropyridine|<span style="color:white;">non-dihydropyridine calcium channel blockers</span>]] if beta-blockers are contraindicated<br>
:❑ [[Blood group|<span style="color:white;">Blood group</span>]] and [[cross match|<span style="color:white;">cross match</span>]] <br> }}</div>
::❑ '''[[Diltiazem|<span style="color:white;">Diltiazem</span>]]'''
|G02=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Titrate [[BP|<span style="color:white;">BP</span>]] between 90-120 mm Hg'''}}</div><div style=" background: #FA8072; text-align: left; padding:0.7em"> {{fontcolor|#F8F8FF|❑ Control heart rate by [[betablockers|<span style="color:white;">betablockers</span>]] before lowering [[BP|<span style="color:white;">BP</span>]] by other agents, as other agents can lead to [[reflex tachycardia|<span style="color:white;">reflex tachycardia</span>]] and worsening of [[aortic dissection|<span style="color:white;">aortic dissection</span>]]<br>
:::❑ 0.25 mg/kg intravenous bolus initially then  5-10 mg/hr infusion
:❑ [[Esmolol|<span style="color:white;">Esmolol</span>]]
:::❑ If necessary increase dose to 15 mg/hr<br>
::❑ 500 micrograms/kg intravenous initially, followed by 50 micrograms/kg/min for 4 min
::'''OR'''
::❑ If necessary increase infusion up to 200 micrograms/kg/min<br>
::'''[[Verapamil|<span style="color:white;">Verapamil</span>]]'''
:❑ [[Metoprolol|<span style="color:white;">Metoprolol</span>]]
:::❑ 0.05 to 0.1 mg/kg IV bolus}}</div>
::❑ 5 mg intravenously every 5-10 minutes
----
::❑ If necessary increase up to a maximum dosage of 15 mg/total dose <br>
<div style="text-align: center; padding:1em">{{fontcolor|#F8F8FF| '''Control pain'''}}</div><div style="text-align: left; padding:1em">{{fontcolor|#F8F8FF| ❑ '''[[Morphine sulphate|<span style="color:white;">Morphine sulphate</span>]]'''<br>
❑ Substitute [[Non-dihydropyridine|<span style="color:white;">non-dihydropyridine calcium channel blockers</span>]] or [[vasodilators|<span style="color:white;">vasodilators</span>]] or [[labetalol|<span style="color:white;">labetalol</span>]]  if [[betablockers|<span style="color:white;">betablockers</span>]] are contraindicated<br>
:2.5-5 mg every 3 to 4 hours, infused over 4-5 minutes}}</div>|DBB=<div style=" text-align: center; width:25em; padding:0.7em">'''[[Aortic dissection resident survival guide#Complete Diagnostic Approach|Continue with the diagnostic approach below]]'''</div>|boxstyle_DAA= background-color: #FA8072}}
:❑ [[Diltiazem|<span style="color:white;">Diltiazem</span>]]
{{familytree  | | | | | |!| | | | | | | | | | | }}
::❑ 0.25 mg/kg intravenous bolus initially then 5-10 mg/hr infusion
{{familytree  | | | | | |!| | | | | | | | | | | | }}
::❑ If necessary increase dose to 15 mg/hr
{{familytree  | | | | | G01 | | | | | | | | | | | | | |G01=<div style="background: #FA8072; text-align:center; padding:0.7em"> {{fontcolor|#F8F8FF|'''Urgent imaging required'''}}</div><div style="background: #FA8072; text-align:left; ; padding:0.7em"> {{fontcolor|#F8F8FF|❑ [[TEE|<span style="color:white;">TEE</span>]] (preferred in hemodynamically unstable) or CT looking for the following: <br>
:❑ [[Verapamil|<span style="color:white;">Verapamil</span>]]
:❑ Location and features of dissection
::❑ 0.05 to 0.1 mg/kg IV bolus
::❑ Proximal vs. Distal
:❑ [[Nitroprusside|<span style="color:white;">Nitroprusside</span>]]
::❑ Involvement of aortic branches
::❑ 0.3 to 0.5 micrograms/kg/min IV initially then increase by 0.5 micrograms/kg/min
:❑ Associated complications
::❑ If necessary increase dose to a maximum of 15 mg/hr
::❑ [[Pericardial effusion|<span style="color:white;">Pericardial effusion</span>]] <br>
: ❑ [[Labetalol|<span style="color:white;">Labetalol</span>]]
::❑ Regional wall motion abnormality <br>
::❑ 1-5 mg/min IV infusion<br>}}</div>|boxstyle = background-color: #FA8072;}}
::❑ [[Aortic regurgitation|<span style="color:white;">Severe aortic regurgitation</span>]] (AR)}} </div>|boxstyle = background-color: #FA8072}}
{{familytree  | | |`|-|-|v|'| | | | | | | | | }}
{{familytree  | | | | | |!| | | | | | | | | | }}
{{familytree  | | | | | H01 | | | | | | | | | | H01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|''' Can [[aortic dissection|<span style="color:white;">aortic dissection</span>]] be confirmed?'''}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | | | | | H01 | | | | | | | | | | H01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|''' Can [[aortic dissection|<span style="color:white;">aortic dissection</span>]] be confirmed?'''}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | | |,|-|-|^|-|-|.| | | | | | | | }}
{{familytree  | | |,|-|-|^|-|-|.| | | | | | | | }}
{{familytree  | | I01 | | | | I02 | | | |I01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Yes'''}}</div>|I02=<div style=" background: #FA8072; text-align: center; padding:0.7em"> {{fontcolor|#F8F8FF|'''No'''}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | | I01 | | | | I02 | | | |I01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Yes'''}}</div>|I02=<div style=" background: #FA8072; text-align: center; padding:0.7em"> {{fontcolor|#F8F8FF|'''No'''}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | |,|^|-|.| | | |!| | | | }}
{{familytree  | | |!| | | | | |!| | | | }}
{{familytree  |J01| | J02 | | J03 | | | | | J01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Type A dissection'''}}</div>|J02=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|'''Type B dissection'''}}</div>|J03=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|Obtain a secondary imaging study, if there is a high clinical suspicion}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | | J01 | | | | J03 | | | | | J01=<div style=" background: #FA8072; text-align: center; width:22em; padding:0.7em">{{fontcolor|#F8F8FF|'''[[Aortic_dissection_resident_survival_guide#Medical_Treatment|<span style="color:white;">Proceed to Management Algorithm</span>]]'''}}</div>||J03=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF|Obtain a secondary imaging study, if there is high clinical suspicion}}</div>|boxstyle = background-color: #FA8072;}}
{{familytree  | |!| | | |!| | | | | | | | | | | |}}
{{familytree  | K01 | | K02 | | | | | | | | | | | |K01=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF| ❑ Transfer to a cardio-thoracic unit for the surgical management}}</div>|K02=<div style=" background: #FA8072; text-align: center; padding:0.7em">{{fontcolor|#F8F8FF| ❑ Initiate medical management unless there is<br>
:❑ Leaking of dissection
:❑ Rupture of dissection
:❑ Malperfusion to any organ}}</div>|boxstyle = background-color: #FA8072;}}
{{Family tree/end}}
{{Family tree/end}}


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{{ familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | | C01 | | | | | | | | | | | | | | | |C01= <div style="text-align: center;  padding:1em;">  '''Examine the patient:''' </div>
{{ familytree | | | | | | | C01 | | | | | | | | | | | | | | | |C01= <div style="text-align: center;  padding:1em;">  '''Examine the patient:''' </div>
<div style="float: left; text-align: left;  padding:1em;">❑ Vitals <br>
<div style="float: left; text-align: left;  padding:1em;">❑ Obtain vitals: <br>
:❑ [[Pulse]]<br>
:❑ [[Pulse]]<br>
::❑ [[Tachycardia]] (suggestive of [[pain]], [[aortic insufficiency]], [[pericardial tamponade]], and [[aortic rupture]] if associated with severe hypotension)<br>
::❑ [[Tachycardia]] (suggestive of [[pain]], [[aortic insufficiency]], [[pericardial tamponade]], and [[aortic rupture]] if associated with severe hypotension)<br>
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::❑ [[Clammy skin|Cold and clammy extremities]]<br>
::❑ [[Clammy skin|Cold and clammy extremities]]<br>
::❑ [[Oliguria]] ([[urine output]] <0.5mL/kg/hr)<br>
::❑ [[Oliguria]] ([[urine output]] <0.5mL/kg/hr)<br>
❑ HEENT examination <br>
Perform a HEENT examination looking for: <br>
:❑ Increased [[JVP]] (suggestive of [[heart failure]])<br>
:❑ Increased [[JVP]] (suggestive of [[heart failure]])<br>
:❑ [[Horner's syndrome]]<br>
:❑ [[Horner's syndrome]]<br>
:❑ [[hoarse|Hoarseness]] due to compression of the left [[recurrent laryngeal nerve]]<br>
:❑ [[hoarse|Hoarseness]] due to compression of the left [[recurrent laryngeal nerve]]<br>
:❑ [[Swelling]] of the neck and face (suggestive of [[superior vena cava syndrome]])<br>  
:❑ [[Swelling]] of the neck and face (suggestive of [[superior vena cava syndrome]])<br>  
Cardiovascular examination <br>
Perform a cardiovascular examination looking for:<br>
:❑ Faint early diastolic murmur (suggestive of acute [[aortic regurgitation]], vs. loud decrescendo diastolic murmur of chronic AR)<ref name="pmid19564568">{{cite journal| author=Stout KK, Verrier ED| title=Acute valvular regurgitation. | journal=Circulation | year= 2009 | volume= 119 | issue= 25 | pages= 3232-41 | pmid=19564568 | doi=10.1161/CIRCULATIONAHA.108.782292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564568  }} </ref><br>
:❑ Faint early diastolic murmur (suggestive of acute [[aortic regurgitation]], vs. loud decrescendo diastolic murmur of chronic AR)<ref name="pmid19564568">{{cite journal| author=Stout KK, Verrier ED| title=Acute valvular regurgitation. | journal=Circulation | year= 2009 | volume= 119 | issue= 25 | pages= 3232-41 | pmid=19564568 | doi=10.1161/CIRCULATIONAHA.108.782292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564568  }} </ref><br>
:❑ [[Pericardial friction rub]] (suggestive of [[pericarditis]])<br>
:❑ [[Pericardial friction rub]] (suggestive of [[pericarditis]])<br>
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::❑ [[Jugular venous distension]] (suggestive of venous hypertension due to decrease cardiac output)<br>
::❑ [[Jugular venous distension]] (suggestive of venous hypertension due to decrease cardiac output)<br>
::❑ Muffled [[heart sounds]] (suggestive of fluid inside the [[pericardium]]) <ref>Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395</ref>
::❑ Muffled [[heart sounds]] (suggestive of fluid inside the [[pericardium]]) <ref>Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395</ref>
Respiratory examination <br>
Perform a respiratory examination looking for:<br>
:❑ [[Kussmaul's sign]] (Paradoxical increase in [[jugular venous pressure]] with [[inspiration]] - Suggestive of tamponade)<br>
:❑ [[Kussmaul's sign]] (Paradoxical increase in [[jugular venous pressure]] with [[inspiration]] - Suggestive of tamponade)<br>
:❑ Decreased movement of the chest<br>
:❑ Decreased movement of the chest<br>
Line 265: Line 246:
:❑ [[Stridor]] and [[wheezing]] (suggestive of compression of the airway)<br>
:❑ [[Stridor]] and [[wheezing]] (suggestive of compression of the airway)<br>
:❑ Decreased [[tactile fremitus]] (suggestive of pleural effusion)<br>
:❑ Decreased [[tactile fremitus]] (suggestive of pleural effusion)<br>
Abdominal examination <br>
Perform an abdominal examination looking for: <br>
:❑ [[Ascites]]<br>
:❑ [[Ascites]]<br>
Neurological examination <br>
Perform a full neurological examination looking for: <br>
:❑ [[Altered mental status]] <br>
:❑ [[Altered mental status]] <br>
:❑ Extremity [[tingling]] and [[numbness]] (suggestive of nerve compression)<br>
:❑ Extremity [[tingling]] and [[numbness]] (suggestive of nerve compression)<br>
:❑ Focal neurological deficits (signs suggestive of [[stroke]]) <br>
:❑ Focal neurological deficits (signs suggestive of [[stroke]]) <br>
Extremity examination <br>
Examine the extremities for: <br>
:❑ [[Edema|Peripheral edema]]<br>
:❑ [[Edema|Peripheral edema]]<br>
:❑ [[Claudication]]</div>}}
:❑ [[Claudication]]</div>}}
Line 361: Line 342:


==Treatment==
==Treatment==
==='''Medical Treatment'''===
==='''Medical Management'''===
Shown below is an algorithm summarizing the medical management of [[aortic dissection]] according to the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher =  | date =  | accessdate = }}</ref>
Shown below is an algorithm summarizing the medical management of [[aortic dissection]] according to the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher =  | date =  | accessdate = }}</ref>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="text-align: center; width:22em; padding:1em">'''Confirmed aortic dissection'''</div>}}
{{familytree | | | | |A01 | | | | | | | | | | |A01=<div style="text-align: center; width:22em; padding:1em">'''Confirmed aortic dissection'''</div>|boxstyle_A01= background-color: #80D4FF}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01=<div style="text-align: left; padding:1em">❑ Consider urgent surgical consultation<br>❑ Consider transfer to other medical facility if resources not available for adequate management</div>}}
{{familytree | | | | | B01 | | | | | | | | | | | | |B01=<div style="text-align: left; padding:1em">❑ Consider urgent surgical consultation<br>❑ Consider transfer to other medical facility if resources not available for adequate management</div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em">❑ Check [[blood pressure]] in both arms prior to initiating treatment<br>
{{familytree | | | | | D01 | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em">❑ Is patient hemodynamically stable ?</div>}}
❑ Use the highest reading for treatment goal<br></div>}}
{{familytree | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}}
 
{{familytree | E01 | | | | | | | | | |E02 | | | | |E01=Yes |E02={{fontcolor|#F8F8FF|No}}|boxstyle_E02= background-color: #FA8072}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}}
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em">❑ Is patient hemodynamically stable ?</div>}}
{{familytree | F01 | | | | | |F02 | | | | | |F03 |F01=<div style="text-align: center; padding:1em">'''Control rate and pressure''' <br>
{{familytree | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}}
(choose '''ONE''' of the following agents)</div><div style="float: left; width:24em; text-align: left; padding:1em">
{{familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | |E01=Yes |E02=No}}
'''[[Beta blockers]]'''<br>
{{familytree | | | | | | | | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}}
<span style="font-size:65%;color:red">Betablockers are contraindicated in [[bradycardia|<span style="color:red;">bradycardia</span>]], [[heart block|<span style="color:red;">heart block</span>]], [[congestive heart failure|<span style="color:red;">decompensated heart failure</span>]], [[hypotension|<span style="color:red;">hypotension</span>]], [[asthma|<span style="color:red;">asthma</span>]], severe [[chronic obstructive pulmonary disease|<span style="color:red;">chronic obstructive pulmonary disease</span>]]</span>
{{familytree | | | | | | | | F01 | | | | | | F02 | | | | | | F03 |F01=<div style="float: left; width:24em; text-align: left; padding:1em">Control rate and pressure <br>
:❑ [[Esmolol]]
: (choose '''ONE''' of the following agents)<br>
::❑ 500 micrograms/kg intravenous initially, followed by 50 micrograms/kg/min for 4 min
: ❑ [[Beta blockers]]<br>
::❑ If necessary increase infusion up to 200 micrograms/kg/min<br>
: <span style="font-size:65%;color:red">Betablockers are contraindicated in [[hypersensitivity|<span style="color:red;">hypersensitivity</span>]], [[bradycardia|<span style="color:red;">bradycardia</span>]], [[heart block|<span style="color:red;">heart block</span>]], [[congestive heart failure|<span style="color:red;">decompensated heart failure</span>]], [[hypotension|<span style="color:red;">hypotension</span>]], [[asthma|<span style="color:red;">asthma</span>]], severe [[chronic obstructive pulmonary disease|<span style="color:red;">chronic obstructive pulmonary disease</span>]]</span>
:'''OR'''
::❑ Administer [[esmolol]]
:❑ [[Metoprolol]]
::: ❑ 500 micrograms/kg intravenous initially, followed by 50 micrograms/kg/min for 4 min
::❑ 5 mg intravenously every 5-10 minutes
:::❑ If necessary increase infusion up to 200 micrograms/kg/min<br>
::❑ If necessary increase up to a maximum dosage of 15 mg/total dose
 
:'''OR'''
'''OR'''
: ❑ [[Labetalol]]
 
::❑ 1-5 mg/min IV infusion<br>
::❑ Administer [[metoprolol]]
:'''OR'''
::: ❑ 5 mg intravenously every 5-10 minutes
''Substitute with [[Non-dihydropyridine|non-dihydropyridine calcium channel blockers]] if [[betablockers]] are contraindicated<br>''
:::❑ If necessary increase up to a maximum dosage of 15 mg/total dose
❑ '''[[Calcium Channel blockers]]'''<br>
<span style="font-size:65%;color:red">Calcium channel blockers are contraindicated in [[hypotension|<span style="color:red;">hypotension</span>]], [[Second degree AV block|<span style="color:red;">second</span>]]- or [[third degree AV block|<span style="color:red;">third-degree atrioventricular block</span>]], [[sick sinus syndrome|<span style="color:red;">sick sinus syndrome</span>]], [[left ventricular dysfunction|<span style="color:red;">left ventricular dysfunction</span>]], [[pulmonary congestion|<span style="color:red;">pulmonary congestion</span>]]</span>
:❑ [[Diltiazem]]
::❑ 0.25 mg/kg intravenous bolus initially then  5-10 mg/hr infusion
::❑ If necessary increase dose to 15 mg/hr<br>
:'''OR'''
:❑ [[Verapamil]]
::❑ 0.05 to 0.1 mg/kg IV bolus
<br>
<br>
:::::OR
'''Titrate therapy:'''<br>
:❑ Substitute [[Non-dihydropyridine|non-dihydropyridine calcium channel blockers]] or [[vasodilators]] or [[labetalol]]  if [[betablockers]] are contraindicated<br>
Goal [[heart rate]] of 60 beats per minute<br>
<span style="font-size:85%;color:red">Calcium channel blockers are contraindicated in [[hypersensitivity|<span style="color:red;">hypersensitivity</span>]], [[hypotension|<span style="color:red;">hypotension</span>]], [[Second degree AV block|<span style="color:red;">second</span>]]- or [[third degree AV block|<span style="color:red;">third-degree atrioventricular block</span>]], [[sick sinus syndrome|<span style="color:red;">sick sinus syndrome</span>]], [[left ventricular dysfunction|<span style="color:red;">left ventricular dysfunction</span>]], [[pulmonary congestion|<span style="color:red;">pulmonary congestion</span>]]</span>
Goal systolic BP of 90-120 mm Hg
::❑ [[Diltiazem]]
:::❑ 0.25 mg/kg intravenous bolus initially then  5-10 mg/hr infusion
:::❑ If necessary increase dose to 15 mg/hr<br>
::❑ [[Verapamil]]
:::❑ 0.05 to 0.1 mg/kg IV bolus
:❑ [[Vasodilators]]<br>
::❑ [[Nitroprusside]]
<span style="font-size:85%;color:red">Nitroprusside is contraindicated in hypersensitivity, poor cerebral ischemia or coronary perfusion</span>
:::❑ 0.3 to 0.5 micrograms/kg/min IV initially then increase by 0.5 micrograms/kg/min
:::If necessary increase dose to a maximum of 15 mg/hr<br>
:: ❑ [[Labetalol]]
:::❑ 1-5 mg/min IV infusion<br>
----
----
Goal [[heart rate]] should be 60 beats per minute<br>
<div style="text-align: center; padding:1em">'''Control pain'''</div>
Goal systolic BP 90-120 mm of Hg<br>
❑ [[Morphine sulphate]]
:2.5-5 mg every 3 to 4 hours, infused over 4-5 minutes</div> |F02=<div style="align: top; text-align: left; width:22em; padding:1em">{{fontcolor|#F8F8FF| ❑ '''[[Aortic dissection resident survival guide#Classification|Type A dissection]]'''
----
----
Pain control<br>
Surgical emergency, expedited transfer to operating room<br>
: ❑ Use [[Opiates]]<br>
❑ Intravenous fluid replacement<br>
::❑ [[Morphine sulphate]]
:❑ Maintain euvolemic status<br>
::: ❑ 2-5 mg intravenously every 5-30 minutes or as needed</div> |F02=<div style="float: left; text-align: left; padding:1em"> ❑ '''[[Aortic dissection resident survival guide#Classification|Type A dissection]]'''
:❑ Titrate to mean arterial pressure of 70 mm Hg<br>
:❑ Consider vasopressors if still hypotensive<br>}}</div>|F03=<div style="float: left; text-align: left; width:22em; padding:1em">{{fontcolor|#F8F8FF|❑ '''[[Aortic dissection resident survival guide#Classification|Type B dissection]]'''
----
----
❑ Is a surgical emergency, do an expedited surgical consultation<br>
❑ Intravenous fluid replacement<br>
<span style="font-size:85%;color:red">Surgery is relatively contraindicated in hemorrhagic stroke</span> <br>
:❑ Maintain euvolemic status<br>
❑ Maintain euvolemic status<br>
:❑ Titrate to mean arterial pressure of 70 mm Hg<br>
:❑ Intravenous fluid replacement<br>
:❑ Consider vasopressors if still hypotensive<br>
:❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of Hg<br>
Rule out a possible complication causing hypotension:<br>
❑ Rule out the following complications using imaging studies:<br>
:❑ Aortic rupture
:❑ [[Cardiac tamponade|Pericardial tamponade]]<br>
:❑ Severe aortic insufficiency
:❑ [[Aortic rupture|Rupture of aorta]]<br>
:❑ Pericardial tamponade
:❑ [[Aortic insufficiency]]<br>
Urgent surgical consultation}}</div>
:❑ [[Myocardial infarction]]</div>[[Image:Type-a-dissection-ct.jpg|thumb|Stanford A type dissection]]|F03=<div style="float: left; text-align: left; padding:1em">❑ '''[[Aortic dissection resident survival guide#Classification|Type B dissection]]'''
|boxstyle_F02= background-color: #FA8072
----
 
❑ Uncomplicated dissection are treated medically<br>
|boxstyle_F03= background-color: #FA8072}}
:❑ Intravenous fluid replacement<br>
{{familytree | |!| | | | | | | |!| | | | | | | |!| |}}
:❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of Hg<br>
{{familytree | G01 |-| G11 | | |!| | |G22  |-|G03  |G01=Systolic blood pressure still >120 mm Hg?|G11=No|G22=Yes|G03=Can hypotension be corrected by surgical intervention?|boxstyle_G22= background-color: #FA8072|boxstyle_G03= background-color: #FA8072}}
:❑ Start vasopressors, if the patient remains [[hypotensive]]
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| |}}
----
{{familytree | H01 | | |!| | | |!| | | |!| | | H03 |H01=Yes|H02=Yes|H03=No}}
❑ Complicated [[aortic dissection]] is treated surgically<br>
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| |}}
:Leaking dissection <br>
{{familytree | I01 | | |!| | | |!| | | |!| | | |!| |I01=<div style="text-align: center; padding:1em">'''Add IV vasodilator with SBP goal <120 mmHg'''</div><div style="text-align: left; padding:1em">❑ Nitroprusside
:❑ Rupture<br>
:❑ 0.3 to 0.5 micrograms/kg/min IV initially then increase by 0.5 micrograms/kg/min<br>
:❑ Malperfusion to a vital organs<br>
:❑ If necessary increase dose to a maximum of 15 mg/hr
::❑ [[Refractory hypertension]] ([[Renal ischemia|decreased renal perfusion]])<br>
</div>}}
::❑ [[Acute abdomen|Tensed abdomen]]<br>
{{familytree | |)|-|-|-|'| | | |!| | | |!| | | |!| |}}
::Progressive [[metabolic acidosis]] <br>
{{familytree | J01 |-|J02  |-|J03  |-|-|'| | | J04 |J01=Proximal dissection<br>(involving ascending aorta)?|J02=Yes|J03='''[[Aortic_dissection_resident_survival_guide#Surgical_Treatment|Proceed to Surgical Management]]'''|J04=<div style="text-align:left; padding:1em;">❑ Continue medical management<br>❑ Maintain SBP<120 mm Hg</div>|boxstyle_J02= background-color: #FA8072|boxstyle_J03= background-color: #FA8072}}
::❑ Increasing [[liver enzymes]]<ref>{{Cite web  | last =  | first =  | title = Predictors of complications in acute type B aortic dissection | url = http://ejcts.oxfordjournals.org/content/22/1/59.full | publisher =  | date =  | accessdate = }}</ref><br>
{{familytree | |!| | | | | | | | | | | | | | | |!| |}}
:❑ Rupture in the [[pericardial sac]](rare)<br>
{{familytree | O01 | | | | | | | | | | | | | | |!| |O01=No}}
::❑ [[Beck's triad]] ([[cardiac tamponade]])<ref>{{Cite web  | last = | first =  | title = Acute Stanford type B dissection and cardiac... [Ann Thorac Surg. 2007] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/17588435 | publisher =  | date =  | accessdate = }}</ref> <br>
{{familytree | |!| | | | | | | | | | | | | | | |!| |}}
❑ Imaging studies to find out contained rupture<br>
{{familytree | K01 | | | | | | | | | | | | | | |!| |K01=<div style="text-align:left; padding:1em;">❑ Continue medical management<br>❑ Maintain SBP<120 mm Hg</div>}}
❑ Perform [[Echocardiography|Transthoracic echocardiogram (TTE)]] to assess cardiac function</div>[[Image:Aortic dissection type B 001.jpg|thumb|Stanford B type dissection]] }}
{{familytree | |!| | | | | | | | | | | | | | | |!| |}}
{{familytree | | | | | | | | |!| | | | | | | |!| | | | | | | |!| |}}
{{familytree | |`|-|-|-|-|-|-| L01 |-|-|-|-|-|-|'| |L01=<div style="text-align:left; padding:1em;">❑ Complications that require operative or interventional management?<br>
{{familytree | | | | | | | | |!| | | | | | | G01 | | | | | | |!| |G01=<div style="float: left; text-align: left; padding:1em">❑ Can the cause of [[hypotension]] respond to surgical management</div>}}
:❑ Limb or mesenteric ischemia<br>
{{familytree | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| |}}
:❑ Progression of dissection<br>
{{familytree | | | | | | | | H01 |-| H02 | | | | | | H03 |-| H04 |H01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely<br>
:❑ Aneurysm expansion<br>
: ❑ Maintain systolic [[BP]] <120 mm of Hg</div> |H02=No |H03=Yes |H04=Consider surgical management}}
:❑ Uncontrolled hypertension<br></div>}}
{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | | | |}}
{{familytree | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01=Yes |I02=No}}
{{familytree | | | | | | | | | M01 | | | | | | | | |M01=<div style="text-align:center; padding:1em;">'''Refer for surgical management'''</div>}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | J01 |-|-|-|-|-| J02 | | | | |J01=<div style="float: left; text-align: left; padding:1em"> ❑ Check if dissection involves [[ascending aorta]]</div> |J02=Yes}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |!| | | | | | | K01 | | | | | | |!| | | | | |K01=No}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |`|-|-| L01 |-|-|'| | | | | | | |!| | | | | |L01=<div style="float: left; text-align: left; padding:1em">❑ Control [[blood pressure]]<br>
: ❑ Intravenous [[vasodilator]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | M01 | | | | | | | | | | |!| | | | | |M01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely<br>
: ❑ Maintain systolic BP <120 mm of Hg</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | N01 |-| N02 |-| N03 |-|-|'| | | | | |N01=<div style="float: left; text-align: left; padding:1em">❑ Check for any complications which might require surgery<br>
----
: ❑ Malperfusion<br>
: ❑ Progressing dissection<br>
: ❑ Expansion of [[aortic aneurysm]]<br>
: ❑ [[Hypertension causes|Uncontrolled or refractory hypertension]] </div> |N02=Yes|N03=<div style="float: left; text-align: left; padding:1em">❑ Consider surgical management</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | O01 | | | | | | | | | | | | | | | | |O01=No}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | P01 | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; padding:1em">❑ Switch to oral medications <br>
:❑ [[Betablockers]]<br>
:❑ [[Antihypertensive]] regimen<br>
----
❑ Follow up in the outpatient
❑ Start long-term [[antihypertensive ]]drug therapy, usually including [[β-blockers]], [[calcium channel blockers]], and [[ACE inhibitors]].
❑ Avoidance of strenuous physical activity.
❑ [[MRI]] may be done before discharge and repeated at 6 mo and 1 yr, then every 1 to 2 yrs.</div>}}
{{familytree/end}}
{{familytree/end}}


==='''Surgical Treatment'''===
==='''Surgical Management'''===
Shown below is an algorithm summarizing the surgical management of [[aortic dissection]] according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher =  | date =  | accessdate = }}</ref>
Surgical management of [[aortic dissection]] according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher =  | date =  | accessdate = }}</ref>


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | A01 |-| A02 |-|-|.| | | | |A01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Imaging study confirms aortic dissection <br> ❑ Check whether dissection occurred in '''[[ascending aorta]]''' </div>|A02=No }}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="text-align: center; width:20em; padding:1em">'''Is the patient hemodynamically stable?'''</div>}}
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | A03 | | | | | | |!| | | | |A03=Yes}}
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | B01 |-| B02 |-| B03 | | |B01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Assess suitability for surgery <br>❑ Patient stable for pre-op testing?</div> |B02=No |B03='''Medical management''' }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | C01 | | | | | | | | | | |C01=Yes }}
{{familytree | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | |A02  | | | |A03  | | | | | | | |A02=Yes|A03=No|boxstyle_A03= background-color: #FA8072}}
{{familytree | | | | | | | | | | D01 |-| D02 |-|.| | | |D01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Age > 40? </div>|D02=No }}
{{familytree | | | | | | | |!| | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |,| D02 |-| D01 | | | | |!| | | | |D01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Age > 40? </div>|D02=No }}
{{familytree | | | | | | | | | | E01 | | | | | |!| | | |E01=Yes }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |!| | | | | E01 | | | | |!| | | | |E01=Yes }}
{{familytree | | | | | | | | | | F01 |-| F02 |-|(| | | |F01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Assess need for pre-operative [[coronary angiography]] <br>
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | |)| F02 |-| F01 | | | | |!| | | | |F01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Assess need for pre-operative [[coronary angiography]] <br>
:❑ Known [[CAD]]?
:❑ Known [[CAD]]?
:❑ Significant risk factors for [[CAD]]? </div>|F02=No}}
:❑ Significant risk factors for [[CAD]]? </div>|F02=No}}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | G01 | | | | | |!| | | |G01=Yes }}
{{familytree | |!| | | | | G01 | | | | |!| | | | |G01=Yes }}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | H01 |-| H02 |-|(| | | |H01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform [[angiography]] <br> Is significant [[CAD]] detected on [[angiography]]?</div> |H02=No }}
{{familytree | |)| H02 |-| H01 | | | | |!| | | | |H01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform [[angiography]]
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
----
{{familytree | | | | | | | | | | I01 | | | | | |!| | | |I01=Yes }}
Significant [[CAD]] detected on [[angiography]]?</div> |H02=No }}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | J01 | | | | | |!| | | |J01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Plan for [[CABG]] at the time of aortic dissection repair </div> }}
{{familytree | |!| | | | | I01 | | | | |!| | | | |I01=Yes }}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | K01 |-|-|-|-|-|'| | | |K01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform urgent operative management </div>}}
{{familytree | |!| | | | | J01 | | | | |!| | | | |J01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Plan for [[CABG]] at the time of aortic dissection repair </div> }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | |!| | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | | | | | | | L01 | | | | | | | | | | |L01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform intra-operative assessment of aortic valve by [[Transesophageal echocardiography|Transesophageal echocardiography (TEE)]] for presence of one of the following: <br>
{{familytree | |`|-|-|-|-|-|^|-|K01  |-|'| | | | |K01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform urgent operative management </div>|boxstyle_K01= background-color: #FA8072}}
{{familytree | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | |L01   | | | | | | | |L01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Evidence of any of the following? <br>
:❑ [[Aortic regurgitation]] <br>
:❑ [[Aortic regurgitation]] <br>
:❑ Dissection of [[aortic sinuses]] </div>}}
:❑ Dissection of [[aortic sinuses]] </div>}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | }}
{{familytree | | | | | | | | |,|-|^|-|.| | | | | | | | | | | }}
{{familytree | | | | | M01 | | | | | | | | M02 | | | | | | |M01=No |M02=Yes }}
{{familytree | | | | | | | | M01 | | M02 | | | | | | | | | |M01=No |M02=Yes }}
{{familytree | | | | | |!| | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | |!| | | |!| | | | | | | | | | | }}
{{familytree | | | | | N01 | | | | | | | | N02 | | | | | | |N01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform graft replacement of [[ascending aorta]] ± [[aortic arch]] </div> |N02=<div style="float: left; text-align: left; width:15em; padding:1em">❑ Perform graft replacement of [[ascending aorta]] ± [[aortic arch]] <br>❑ Consider repair/replacement of [[aortic valve]] </div>}}
{{familytree | | | | | | | | N01 | | N02 | | | | | | |N01=<div style="float: left; text-align: left; width:20em; padding:1em">❑ Perform graft replacement of [[ascending aorta]] ± [[aortic arch]] </div> |N02=<div style="float: left; text-align: left; width:15em; padding:1em">❑ Perform graft replacement of [[ascending aorta]] ± [[aortic arch]] <br>❑ Consider repair/replacement of [[aortic valve]] </div>}}
{{familytree/end}}
{{familytree/end}}


Line 523: Line 471:
===History and Examination===
===History and Examination===
*For pre-test risk determination include information about:
*For pre-test risk determination include information about:
**[[Medical History]]
**[[Medical history]]
**[[Family history]] and ask specifically for [[family history]] of [[aortic dissection]] or [[thoracic aneurysm]]
**[[Family history]] and ask specifically for [[family history]] of [[aortic dissection]] or [[thoracic aneurysm]]
**[[Pain history]]
**[[Pain history]]
Line 552: Line 500:


===Screening Tests===
===Screening Tests===
*Do a [[echocardiography|transesophageal echocardiography (TEE)]] in the emergency room. This is the preferred approach. If the patient is hemodynamically unstable, then a [[echocardiography|transesophageal echo]] can be performed in the operating room  after the patient has been induced and is being prepared for surgery.
*Do an emergent CT or a [[echocardiography|transesophageal echocardiography (TEE)]]. If the patient is hemodynamically unstable, then a [[echocardiography|transesophageal echo]] can be performed in the operating room  after the patient has been induced and is being prepared for surgery.
*Do a [[Magnetic resonance imaging|magnetic resonance imaging contrast aortography (MRI)]] only if:
*Do a [[Magnetic resonance imaging|magnetic resonance imaging contrast aortography (MRI)]] only if:
**A patient who has chronic [[chest pain]] who is hemodynamically stable
**A patient who has chronic [[chest pain]] who is hemodynamically stable
Line 558: Line 506:
*Do an [[EKG]] when patients presents with symptoms of dissection.([[ACC AHA guidelines classification scheme|class I, level of evidence B]])
*Do an [[EKG]] when patients presents with symptoms of dissection.([[ACC AHA guidelines classification scheme|class I, level of evidence B]])
*Treat the patient as an acute cardiac event, if [[ST elevation]] is present in [[EKG]] then, unless the patient has high risk factors for [[Aortic dissection|acute dissection]].
*Treat the patient as an acute cardiac event, if [[ST elevation]] is present in [[EKG]] then, unless the patient has high risk factors for [[Aortic dissection|acute dissection]].
*Perform [[coronary angiography]], followed by [[thrombolysis]] or [[percutaneous coronary intervention]], if [[EKG]] shows ST elevation with no dissection features.
*Order an [[X-ray]] for all patients with intermediate to low risk to rule out an alternate diagnosis.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Do order a [[X-ray]] for all patients with intermediate risk and a low risk to rule out alternate diagnosis.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Evaluate high risk patients by [[transesophageal echocardiogram]], [[computed tomography]] or [[magnetic resonance imaging]] to rule out dissection.([[ACC AHA guidelines classification scheme|class I, level of evidence B]])
*Evaluate high risk patients by [[transesophageal echocardiogram]], [[computed tomography]] or [[magnetic resonance imaging]] to rule out dissection.([[ACC AHA guidelines classification scheme|class I, level of evidence B]])
*Obtain a secondary imaging study, if the initial aortic imaging studies are non conclusive, and there is a high clinical suspicion.([[ACC AHA guidelines classification scheme|class III, level of evidence C]])
*Obtain a secondary imaging study, if the initial aortic imaging studies are non conclusive, and there is a high clinical suspicion.([[ACC AHA guidelines classification scheme|class III, level of evidence C]])
*Do a plasma smooth muscle [[myosin]] heavy chain protein, [[D-dimer]] and high sensitive [[C-reactive protein]] to rule out alternate diagnosis.


===Initial Management===
===Initial Management===
*Medical management should be aimed at decreasing aortic wall stress.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Medical management should be aimed at decreasing aortic wall stress.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Titrate [[beta blocker]] to maintain [[heart rate]]  of 60 beats/ minute.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Titrate [[beta blocker]] to maintain [[heart rate]]  of 60 beats/minute.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Use [[calcium channel blockers|nondihyropyridine calcium channel blockers]] to control rate, if [[beta blockers]] are contraindicated.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Use [[calcium channel blockers|nondihyropyridine calcium channel blockers]] to control rate, if [[beta blockers]] are contraindicated.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Use [[angiotensin converting enzyme]] and other [[vasodilators]] to maintain end organ perfusion, if [[BP]] remains above 120 mm of Hg, after medical treatment.([[ACC AHA guidelines classification scheme|class I, level of evidence C]]).
*Use [[angiotensin converting enzyme]] (ACE) inhibitors or [[vasodilators]] to maintain end organ perfusion, if [[BP]] remains above 120 mm of Hg, after medical treatment.([[ACC AHA guidelines classification scheme|class I, level of evidence C]]).


===Definitive Management===
===Definitive Management===
*Do a definitive aortic imaging study, if [[chest X-ray]] demonstrates [[widened mediastinum]].
*Aim to curtail [[heart rate]] less than 60 beats/minute and [[blood pressure|systolic blood pressure]] between 90 and 120 mm of Hg.
*Use [[sodium nitroprusside]] as the first line for the treatment of [[hypertension]].  [[Nicardipine]], [[nitroglycerin]] and [[fenoldopam]] can also be used.
*Use [[esmolol]] in [[asthma]], [[congestive heart failure]] or [[chronic obstructive pulmonary disease]].
*Use [[labetalol]] to maintain [[heart rate]] and [[blood pressure]], it prevents usage of another [[vasodilator]].
*Do a [[pericardiocentesis]] for pericardial bleeding and dissection related [[hemopericardium]].
*Do a [[pericardiocentesis]] for pericardial bleeding and dissection related [[hemopericardium]].
*Do a plasma smooth muscle [[myosin]] heavy chain protein, [[D-dimer]] and high sensitive [[C-reactive protein]] to rule out alternate diagnosis.
*Order a surgical consultation for all patients once diagnosed with [[aortic dissection]].  This applies to patients presenting with dissection at any location.  ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Order a surgical consultation for all patients once diagnosed with [[aortic dissection]].  This applies to patients presenting with dissection at any location.  ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Do an emergent repair in acute dissection of [[ascending aorta]] to prevent complications like rupture.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Perform an emergent repair in acute dissection of [[ascending aorta]] to prevent complications like rupture.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Consider surgical repair for all [[Aortic dissection resident survival guide#Classification|type A dissections]] as they involve the [[aortic valve]]. [[Aortic dissection resident survival guide#Classification|type A]]|Ascending aortic dissections (Type A Stanford)]] often involve the [[aortic valve]], which having lost its suspensory support, telescopes down into the aortic root, resulting in [[aortic regurgitation|aortic incompetence]].  This needs re-suspending to re-seat the valve and repair / prevent [[coronary artery]] injury.  The area of dissection is removed and replaced with a dacron graft to prevent further dissection from occurring.
*Consider surgical repair for all [[Aortic dissection resident survival guide#Classification|type A dissections]] as they involve the [[aortic valve]]. [[Aortic dissection resident survival guide#Classification|type A]]|Ascending aortic dissections (Type A Stanford)]] often involve the [[aortic valve]], which having lost its suspensory support, telescopes down into the aortic root, resulting in [[aortic regurgitation|aortic incompetence]].  This needs re-suspending to re-seat the valve and repair / prevent [[coronary artery]] injury.  The area of dissection is removed and replaced with a dacron graft to prevent further dissection from occurring.
*Suspect  malperfusion in [[Aortic dissection resident survival guide#Classification|type B aortic dissection]], if following sings are present, [[Refractory hypertension]] ([[Renal ischemia|decreased renal perfusion]]), [[acute abdomen|tensed abdomen]], progressive [[metabolic acidosis]], increasing [[liver enzymes]] (impaired perfusion of [[truncus coeliacus]], [[mesenteric arteries]]).<ref>{{Cite web  | last =  | first =  | title = Predictors of complications in acute type B aortic dissection | url = http://ejcts.oxfordjournals.org/content/22/1/59.full | publisher =  | date =  | accessdate = }}</ref>
*Suspect  malperfusion in [[Aortic dissection resident survival guide#Classification|type B aortic dissection]], if following sings are present, [[Refractory hypertension]] ([[Renal ischemia|decreased renal perfusion]]), [[acute abdomen|tensed abdomen]], progressive [[metabolic acidosis]], increasing [[liver enzymes]] (impaired perfusion of truncus celiacus, [[mesenteric arteries]]).<ref>{{Cite web  | last =  | first =  | title = Predictors of complications in acute type B aortic dissection | url = http://ejcts.oxfordjournals.org/content/22/1/59.full | publisher =  | date =  | accessdate = }}</ref>
*Consider medical management for [[Aortic dissection resident survival guide#Classification|type B dissections]], unless there is leaking, rupture or compromise to other organs, e.g. [[kidneys]] and life threatening conditions like [[shock|perfusion deficit]], dissection enlargement, aneurysm enlargement or [[blood pressure]] refractory to treatment.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Consider medical management for [[Aortic dissection resident survival guide#Classification|type B dissections]], unless there is leaking, rupture or compromise to other organs, e.g. [[kidneys]] and life threatening conditions like [[shock|perfusion deficit]], dissection enlargement, aneurysm enlargement or [[blood pressure]] refractory to treatment.([[ACC AHA guidelines classification scheme|class I, level of evidence C]])
*Do a [[MRI]] before discharge and repeat at 6 mo and 1 yr, then every 1 to 2 yr.
*Perform an [[MRI]] before discharge and repeat at 6 mo and 1 yr, then every 1 to 2 yr.


==Dont's==
==Dont's==
*Don't delay aortic imaging even if chest x-ray is negative ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]).
*Don't delay aortic imaging even if chest x-ray is negative ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]).
*Don't use [[beta blocker]] in patients having [[aortic regurgitation]] as they may block the [[tachycardia ]]caused by compensation.
*Don't use [[beta blocker]] among patients with severe acute [[aortic regurgitation]] as they inhibit the compensatory [[tachycardia]] needed to maintain cardiac output.
*Don't use [[nitroprusside]]  without a [[β-blocker]] or [[calcium channel blocker]] otherwise dissection worsens because of reflex sympathetic activation.  This causes vasodilation  which can increase ventricular inotropy and aortic shear stress.
*Don't use [[nitroprusside]]  without a [[β-blocker]] or non-dihydropyridine [[calcium channel blocker]] in order to prevent reflex sympathetic activation which can increase aortic shear stress and potentially worsen the dissection.
*Don't use [[vasodilator]] before heart rate is controlled otherwise there would be [[reflex tachycardia]] which would increase the stress on aorta and worsening the dissection.
*[[Hemorrhagic stroke]] is a relative contraindication to urgent surgical intervention done for [[Aortic dissection resident survival guide#Classification|type A tears]], as intraoperative heparinization and restoration of cerebral blood flow can worsen ongoing [[stroke]] outcomes.
*[[Hemorrhagic stroke]] is a relative contraindication to urgent surgical intervention done for [[Aortic dissection resident survival guide#Classification|type A tears]], as intraoperative heparinization and restoration of cerebral blood flow can worsen ongoing [[stroke]] outcomes.
*Avoid strenous physical exercise.
*Avoid [[antihypertensives]] that act mainly by [[vasodilation]] ([[hydralazine]], [[minoxidil]]).
*Avoid [[β-blockers]] that have intrinsic sympathomimetic action ([[acebutolol]], [[pindolol]]).


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[CME Category::Cardiology]]


[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
{{WH}}
{{WS}}

Latest revision as of 14:10, 27 August 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Serge Korjian M.D.; Chetan Lokhande, M.B.B.S [2]; Pratik Bahekar, MBBS [3]

Aortic dissection resident survival guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment
Medical
Surgical
Do's
Dont's

Overview

Aortic dissection (AD) is a disruption of the medial layer of the aorta triggered by intramural bleeding. It is commonly due to an intimal tear that causes tracking of blood in a dissection plane within the media. Blood accumulation results in a separation of the aortic wall layers with ensuing formation of a true lumen and a false lumen with or without communication between the two. Aortic dissection is a medical emergency and can quickly lead to death if not treated urgently. Patients classically present with abrupt onset of severe, knife-like chest (most common), back, or abdominal pain. Other important features that increases the probability of aortic dissection include pulse deficits, systolic blood pressure differences between limbs, focal neurologic deficits, new aortic murmurs, shock, and a history of connective tissue disease and aortic valve disease. CT, MRI, or transesophageal echocardiography (TEE) may be used for the diagnosis AD, although CT is preferred because of it's speed, excellent sensitivity, and superiority in diagnosing arch vessel involvement. Serial imaging is recommended to monitor for progression of the dissection. After excluding possible aortic regurgitation, intravenous beta-blockers should be initiated in all patients to reduce the systolic blood pressure (SBP) to 100 to 120 mmHg and controlling the heart rate, to minimize the shear stress on the aortic wall. Treatment depends on the anatomic location of the dissection and complications. Uncomplicated type B dissections should be treated medically whereas type A dissections and complicated type B dissections should be treated surgically. Complications of AD include aortic regurgitation, myocardial ischaemia or infarction, pleural effusion, stroke, mesenteric ischemia, and acute kidney injury.[1]

Classification

DeBakey and Stanford systems are the commonly used systems to classify aortic dissection.[2][3][4][5]

Proximal Dissections

Originate in the ascending aorta and may propagate to involve the aortic arch, and possibly part of the descending aorta (include Debakey type I and II, and Stanford type A)[6]

Distal Dissections

Originate in the descending aorta (distal to left subclavian artery) and propagate distally, rarely extends proximally (include Debakey type IIIa and IIIb, and Stanford type B)

Click here for the detailed classification schemes.

Causes

Life Threatening Causes

Aortic dissection is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[7]
Boxes in red signify that an urgent management is needed.

Abbreviations: AVR: Aortic valve replacement; BP Blood Pressure, CCU: Coronary care unit; CHF: Congestive cardiac failure; CXR: Chest X-ray; EKG: Electrocardiogram; MI: Myocardial infarction; OR: Operating room; TAVR: Transcatheter aortic valve replacement; TEE: Transesophageal echocardiogram; TTE: Transthoracic echocardiogram; HEENT: Head eye ear nose throat

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of acute aortic dissection
Chest pain or back pain or abdominal pain
❑ Sudden in onset
Tearing or sharp in quality
❑ Increasing in intensity

Associated with any of the following:
❑ Unexplained syncope
❑ Focal neurological deficits
Unequal pulses or BPs in the limbs
❑ Perfusion deficits

Refractory hypertension (decreased renal perfusion)
❑ Tensed abdomen
❑ Progressive metabolic acidosis
❑ Increasing liver enzymes[8]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have the following findings which require urgent management?
❑ Hypotension or shock
❑ Perfusion deficits
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Attempt to stabilize patient
❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Consider intubation if the patient's airway is compromised, has a glasgow coma scale (GCS < 8) or profound haemodynamic instability
❑ Administer oxygen and maintain a saturation >90%
❑ Secure 2 large-bore intravenous lines (IVs) and initiate fluid resuscitation
❑ Titrate fluids to a mean arterial blood pressure of 70 mm Hg, overzealous fluid administration may lead to progression of the dissection
❑ Consider vasopressors only if patient remains hypotensive despite fluids

❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
❑ Consider intra-arterial BP monitoring
❑ Place an indwelling urethral catheter and monitor urine output
❑ Frequently assess mental status and check for focal neurologic deficits
❑ Monitor development or progression of carotid, brachial, or femoral bruits
❑ Type and crossmatch patient for possible blood transfusion

❑ Obtain blood for CBC, electrolytes, BUN, creatinine, LFTS, and troponin I, and CK-MB

Control blood pressure
❑ Beta blockers are first-line agents, as they circumvent the reflex tachycardia associated with blood pressure lowering
Esmolol
❑ 500 micrograms/kg intravenous push initially, followed by 50 micrograms/kg/min for 4 min
❑ If necessary increase infusion up to 200 micrograms/kg/min
OR
Metoprolol
❑ 5 mg intravenously every 5-10 minutes
❑ If necessary increase up to a maximum dosage of 15 mg/total dose
OR
Labetalol
❑ 1-5 mg/min IV infusion
OR

❑ Substitute with non-dihydropyridine calcium channel blockers if beta-blockers are contraindicated

Diltiazem
❑ 0.25 mg/kg intravenous bolus initially then 5-10 mg/hr infusion
❑ If necessary increase dose to 15 mg/hr
OR
Verapamil
❑ 0.05 to 0.1 mg/kg IV bolus

Control pain
Morphine sulphate
❑ 2.5-5 mg every 3 to 4 hours, infused over 4-5 minutes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urgent imaging required
TEE (preferred in hemodynamically unstable) or CT looking for the following:
❑ Location and features of dissection
❑ Proximal vs. Distal
❑ Involvement of aortic branches
❑ Associated complications
Pericardial effusion
❑ Regional wall motion abnormality
Severe aortic regurgitation (AR)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Can aortic dissection be confirmed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a secondary imaging study, if there is high clinical suspicion
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[9]

 
 
 
 
 
 
Characterize the symptoms:
Chest pain
❑ Tearing, ripping, sharp. stabbing, or knife-like
❑ Sudden onset and increasing in intensity
❑ Worsened by deep breathing or cough and
relieved by sitting upright (suggestive of hemorrhage into the pericardial sac).

Neck, throat, and jaw pain
Abdominal pain or back pain (think of associated mesenteric ischemia)
Syncope in 50% of cases (suggestive of hemorrhage into the pericardial sac causing pericardial tamponade)
Palpitation
❑ Rapid, weak pulse
Dyspnea
Rapid breathing
Orthopnea
Hemoptysis (suggestive of compression of and erosion into the bronchus)
Stridor (suggestive of compression of the airway)
Flank pain
Oliguria/ anuria (suggestive of involvement of the renal arteries causing pre-renal kidney injury).[10] [11] [12] [13]
Nausea and vomiting
Dysphasia(suggestive of pressure on the esophagus)
Hematemesis
Gastrointestinal bleeding
Altered mental status
❑ Symptoms suggestive of stroke e.g. paraplegia, numbness and tingling (suggestive of involvement of cerebral or spinal arteries)
Horner's syndrome (suggestive of compression of the superior cervical ganglia)

Drooping of eyelids (ptosis)
Decreased or no sweating (anhidrosis)
Miosis

Hoarseness of voice (suggestive of compression of the recurrent laryngeal nerve)
Claudication (suggestive of iliac artery occlusion)

❑ Painless dissection (15 – 55 %)(unexplained syncope, stroke or congestive heart failure (CHF))
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:
❑ Past medical history
Hypertension (most important risk factor present in >70% of patients)
Pheochromocytoma

❑ Family history
Connective tissue disorder

❑ Marfan syndrome
❑ Ehlers-Danlos syndrome
❑ Loeys-Dietz syndrome
❑ Polycystic kidney disease

❑ Anatomic defects

Biscuspid aortic valve
❑ Aortic valve disease
❑ Aortic root disorders
Aortic aneurysm
Coarctation of aorta

❑ Iatrogenic

❑ Recent aortic manipulation
Chronic steroid usage
Immunosuppressive therapy

❑ Social history

Cocaine abuse
❑ Heavy weight lifting

Trauma
❑ Other genetic disorders

Turners syndrome (usually due to bicuspid aortic valve)
Familial thoracic aneurysm and dissection syndrome

❑ Inflammatory vasculitis

Takayasu arteritis
Giant cell arteritis
Behcet's arteritis

Pregnancy

Aortitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Obtain vitals:
Pulse
Tachycardia (suggestive of pain, aortic insufficiency, pericardial tamponade, and aortic rupture if associated with severe hypotension)
Wide pulse pressure (suggestive of acute aortic insufficiency)
Pulsus paradoxus (suggestive of pericardial tamponade)
Pulse deficit involving carotid, femoral or subclavian artery
❑ Absent femoral pulse
Blood pressure
❑ Difference in the blood pressure in both extremities
Hypertension (due to pain and catecholamine surge)
Hypotension (grave prognostic indicator, suggestive of pericardial tamponade, severe aortic insufficiency, or aortic rupture)
❑ Signs of shock (hypoperfusion)
Hypotension (SBP < 90 mm of Hg or drop in mean arterial pressure >30 mm of Hg)
Altered mental status
Cold and clammy extremities
Oliguria (urine output <0.5mL/kg/hr)

❑ Perform a HEENT examination looking for:

❑ Increased JVP (suggestive of heart failure)
Horner's syndrome
Hoarseness due to compression of the left recurrent laryngeal nerve
Swelling of the neck and face (suggestive of superior vena cava syndrome)

❑ Perform a cardiovascular examination looking for:

❑ Faint early diastolic murmur (suggestive of acute aortic regurgitation, vs. loud decrescendo diastolic murmur of chronic AR)[14]
Pericardial friction rub (suggestive of pericarditis)
❑ Clicks (suggestive of pseudoprolapse/true prolapse of mitral and/or tricuspid valve)
Beck's triad (suggestive of cardiac tamponade)
Hypotension (suggestive of decreased stroke volume)
Jugular venous distension (suggestive of venous hypertension due to decrease cardiac output)
❑ Muffled heart sounds (suggestive of fluid inside the pericardium) [15]

❑ Perform a respiratory examination looking for:

Kussmaul's sign (Paradoxical increase in jugular venous pressure with inspiration - Suggestive of tamponade)
❑ Decreased movement of the chest
❑ Stony dullness to percussion (suggestive of hemothorax and / or pleural effusion
❑ Diminished breath sounds
Crackles / crepitations / rales (suggestive of pulmonary edema due to acute aortic insufficiency)
Stridor and wheezing (suggestive of compression of the airway)
❑ Decreased tactile fremitus (suggestive of pleural effusion)

❑ Perform an abdominal examination looking for:

Ascites

❑ Perform a full neurological examination looking for:

Altered mental status
❑ Extremity tingling and numbness (suggestive of nerve compression)
❑ Focal neurological deficits (signs suggestive of stroke)

❑ Examine the extremities for:

Peripheral edema
Claudication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternate diagnosis:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Focused bedside pre-test risk assessment

High risk conditions[16]

❑ Marfan syndrome
❑ Connective tissue disease
❑ Family history of aortic disease
❑ Known aortic valve disease
❑ Recent aortic manipulation
❑ Known thoracic aortic aneurysm
❑ Aortic disorder

High risk pain features[16]

❑ Chest, back, or abdominal pain
❑ Abrupt onset
❑ Severe intensity
❑ Ripping, tearing, sharp, or stabbing

High risk exam features[16]

❑ Perfusion deficits
❑ Pulse deficit
❑ Systolic blood pressure differential
❑ Focal neurological deficit
❑ Murmur of aortic insufficiency
❑ Hypotension or shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low pre-test probability
(No features present)
High threshold for aortic imaging
 
 
 
 
 
 
Intermediate pre-test probability
(1 feature present)
Intermediate threshold for aortic imaging
 
 
 
 
High pre-test probability
(2 or more features present)
Immediate surgical evaluation and expedited aortic imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Can an alternate diagnosis be identified?
 
 
 
 
 
 
❑ Order an EKG
❑ Does EKG show ST elevation ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
No
 
 
Yes
 
 
❑ Consider immediate surgical consultation and do aortic imaging as soon as possible
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat accordingly
 
❑ Is there evidence of:
❑ Unexplained hypotension?
Widened mediastinum on CXR?
 
❑ Can an alternate diagnosis be identified?
 
 
 
❑ Treat like a primary acute coronary syndrome (ACS)
❑ If perfusion deficits are present then consider immediate coronary reperfusion therapy
❑ Identifiable culprit lesion on coronary angiography?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
No
 
Yes
Treat accordingly
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check risk factors for Thoracic aortic disease (TAD)
❑ Advanced age
❑ Risk factor for aortic diseases
Syncope
❑ Do a detailed aortic imaging for thoracic aortic disease
 
 
 
 
 
 
 
 
 
 
Detailed and accelerated aortic imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Aortic Imaging
Transesophageal echocardiography (TEE) (preferred in unstable patients)
Computed tomography(chest to pelvis; better visualization of aortic branch involvement)
Magnetic resonance imaging(chest to pelvis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Can aortic dissection be confirmed by imaging study
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Start appropriate therapy
 
 
 
❑ Obtain a secondary imaging study if there is high clinical suspicion, even if the initial aortic imaging studies are negative
 
 
 
 
 
 
 

Treatment

Medical Management

Shown below is an algorithm summarizing the medical management of aortic dissection according to the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[9]

 
 
 
 
Confirmed aortic dissection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider urgent surgical consultation
❑ Consider transfer to other medical facility if resources not available for adequate management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Is patient hemodynamically stable ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Control rate and pressure
(choose ONE of the following agents)

Beta blockers
Betablockers are contraindicated in bradycardia, heart block, decompensated heart failure, hypotension, asthma, severe chronic obstructive pulmonary disease

Esmolol
❑ 500 micrograms/kg intravenous initially, followed by 50 micrograms/kg/min for 4 min
❑ If necessary increase infusion up to 200 micrograms/kg/min
OR
Metoprolol
❑ 5 mg intravenously every 5-10 minutes
❑ If necessary increase up to a maximum dosage of 15 mg/total dose
OR
Labetalol
❑ 1-5 mg/min IV infusion
OR

Substitute with non-dihydropyridine calcium channel blockers if betablockers are contraindicated
Calcium Channel blockers
Calcium channel blockers are contraindicated in hypotension, second- or third-degree atrioventricular block, sick sinus syndrome, left ventricular dysfunction, pulmonary congestion

Diltiazem
❑ 0.25 mg/kg intravenous bolus initially then 5-10 mg/hr infusion
❑ If necessary increase dose to 15 mg/hr
OR
Verapamil
❑ 0.05 to 0.1 mg/kg IV bolus


Titrate therapy:
❑ Goal heart rate of 60 beats per minute
❑ Goal systolic BP of 90-120 mm Hg


Control pain

Morphine sulphate

❑ 2.5-5 mg every 3 to 4 hours, infused over 4-5 minutes
 
 
 
 
 
Type A dissection

❑ Surgical emergency, expedited transfer to operating room
❑ Intravenous fluid replacement

❑ Maintain euvolemic status
❑ Titrate to mean arterial pressure of 70 mm Hg
❑ Consider vasopressors if still hypotensive
 
 
 
 
 
Type B dissection

❑ Intravenous fluid replacement

❑ Maintain euvolemic status
❑ Titrate to mean arterial pressure of 70 mm Hg
❑ Consider vasopressors if still hypotensive

❑ Rule out a possible complication causing hypotension:

❑ Aortic rupture
❑ Severe aortic insufficiency
❑ Pericardial tamponade
❑ Urgent surgical consultation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Systolic blood pressure still >120 mm Hg?
 
No
 
 
 
 
 
 
Yes
 
Can hypotension be corrected by surgical intervention?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Add IV vasodilator with SBP goal <120 mmHg
❑ Nitroprusside
❑ 0.3 to 0.5 micrograms/kg/min IV initially then increase by 0.5 micrograms/kg/min
❑ If necessary increase dose to a maximum of 15 mg/hr
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal dissection
(involving ascending aorta)?
 
Yes
 
Proceed to Surgical Management
 
 
 
 
 
 
❑ Continue medical management
❑ Maintain SBP<120 mm Hg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue medical management
❑ Maintain SBP<120 mm Hg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Complications that require operative or interventional management?
❑ Limb or mesenteric ischemia
❑ Progression of dissection
❑ Aneurysm expansion
❑ Uncontrolled hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer for surgical management
 
 
 
 
 
 
 
 

Surgical Management

Surgical management of aortic dissection according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[9]

 
 
 
 
 
 
 
 
 
Is the patient hemodynamically stable?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
❑ Age > 40?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
❑ Assess need for pre-operative coronary angiography
❑ Known CAD?
❑ Significant risk factors for CAD?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
❑ Perform angiography
Significant CAD detected on angiography?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Plan for CABG at the time of aortic dissection repair
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform urgent operative management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Evidence of any of the following?
Aortic regurgitation
❑ Dissection of aortic sinuses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform graft replacement of ascending aorta ± aortic arch
 
❑ Perform graft replacement of ascending aorta ± aortic arch
❑ Consider repair/replacement of aortic valve
 
 
 
 
 
 

Do's

History and Examination

Screening Tests

Initial Management

Definitive Management

Dont's

References

  1. 1.0 1.1 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H; et al. (2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  2. Nienaber, CA.; Eagle, KA. (2003). "Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies". Circulation. 108 (5): 628–35. doi:10.1161/01.CIR.0000087009.16755.E4. PMID 12900496. Unknown parameter |month= ignored (help)
  3. Tsai, TT.; Nienaber, CA.; Eagle, KA. (2005). "Acute aortic syndromes". Circulation. 112 (24): 3802–13. doi:10.1161/CIRCULATIONAHA.105.534198. PMID 16344407. Unknown parameter |month= ignored (help)
  4. DEBAKEY, ME.; HENLY, WS.; COOLEY, DA.; MORRIS, GC.; CRAWFORD, ES.; BEALL, AC. (1965). "SURGICAL MANAGEMENT OF DISSECTING ANEURYSMS OF THE AORTA". J Thorac Cardiovasc Surg. 49: 130–49. PMID 14261867. Unknown parameter |month= ignored (help)
  5. Daily, PO.; Trueblood, HW.; Stinson, EB.; Wuerflein, RD.; Shumway, NE. (1970). "Management of acute aortic dissections". Ann Thorac Surg. 10 (3): 237–47. PMID 5458238. Unknown parameter |month= ignored (help)
  6. DeBakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 1965;49:130-49. PMID 14261867.
  7. "http://www.cdemcurriculum.org/ssm/cardiovascular/cv_tad.php". External link in |title= (help)
  8. "Predictors of complications in acute type B aortic dissection".
  9. 9.0 9.1 9.2 "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)
  10. Saner, H.E., et al., Aortic dissection presenting as Pericarditis. Chest, 1987. 91(1): p. 71-4. PMID 3792088
  11. Rosman, H.S., et al., Quality of history taking in patients with aortic dissection. Chest, 1998. 114(3): p. 793-5. PMID 9743168
  12. Hagan, P.G., et al., The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000. 283(7): p. 897-903. PMID 10685714
  13. von Kodolitsch, Y., A.G. Schwartz, and C.A. Nienaber, Clinical prediction of acute aortic dissection. Arch Intern Med, 2000. 160(19): p. 2977-82. PMID 11041906
  14. Stout KK, Verrier ED (2009). "Acute valvular regurgitation". Circulation. 119 (25): 3232–41. doi:10.1161/CIRCULATIONAHA.108.782292. PMID 19564568.
  15. Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395
  16. 16.0 16.1 16.2 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.
  17. "Predictors of complications in acute type B aortic dissection".

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