Aortic dissection resident survival guide: Difference between revisions

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{{familytree | | | | | | A01 | | | | | | | | | | | | | | | |A01=<div style="text-align: center; padding:1em;">  '''Characterize the symptoms:''' </div>
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="text-align: center; padding:1em;">  '''Characterize the symptoms:''' </div>
<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ [[Chest pain]] <br>
<div style="float: left; text-align: left; width: 30em; padding:1em;">❑ [[Chest pain]] <br>
:❑ Tearing, ripping, sharp. stabbing, or knife-like <br>
:❑ Tearing, ripping, sharp. stabbing, or knife-like <br>
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❑ [[Claudication]] (suggestive of [[iliac artery]] occlusion)<br>
❑ [[Claudication]] (suggestive of [[iliac artery]] occlusion)<br>
❑ Painless dissection (15 – 55 %)(unexplained [[syncope]], [[stroke]] or [[congestive heart failure|congestive heart failure (CHF)]]) </div>}}
❑ Painless dissection (15 – 55 %)(unexplained [[syncope]], [[stroke]] or [[congestive heart failure|congestive heart failure (CHF)]]) </div>}}
{{ familytree | | | | | | |!| | | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | B01 | | | | | | | | | | | | | | | | |B01=<div style="text-align: center;  padding:1em;"> '''Obtain a detailed history:''' </div><div style="float: left; text-align: left;  padding:1em;">❑ Past medical history<br>
{{ familytree | | | | | | | B01 | | | | | | | | | | | | | | | |B01=<div style="text-align: center;  padding:1em;"> '''Obtain a detailed history:''' </div><div style="float: left; text-align: left;  padding:1em;">❑ Past medical history<br>
:❑ [[Hypertension]] (most important risk factor present in >70% of patients)<br>
:❑ [[Hypertension]] (most important risk factor present in >70% of patients)<br>
:❑ [[Pheochromocytoma]]<br>
:❑ [[Pheochromocytoma]]<br>
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❑ [[Pregnancy]]<br>
❑ [[Pregnancy]]<br>
❑ [[Aortitis]] </div>}}
❑ [[Aortitis]] </div>}}
{{ familytree | | | | | | |!| | | | | | | | | | | | | | | | | | | }}
{{ 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;">❑ Vitals <br>
:❑ [[Pulse]]<br>
:❑ [[Pulse]]<br>
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:❑ [[Edema|Peripheral edema]]<br>
:❑ [[Edema|Peripheral edema]]<br>
:❑ [[Claudication]]</div>}}
:❑ [[Claudication]]</div>}}
{{ familytree | | | | | | |!| | | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | D01 | | | | | | | | | | | | | | | | |D01=<div style="text-align: center;  padding:1em;">'''Consider alternate diagnosis:'''</div><div style="text-align: left;  padding:1em;">
{{ familytree | | | | | | | D01 | | | | | | | | | | | | | | | |D01=<div style="text-align: center;  padding:1em;">'''Consider alternate diagnosis:'''</div><div style="text-align: left;  padding:1em;">
:❑ [[Aortic regurgitation]]
:❑ [[Aortic regurgitation]]
:❑ [[Aortic stenosis]]
:❑ [[Aortic stenosis]]
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:❑ [[Pleural effusion]]
:❑ [[Pleural effusion]]
:❑ [[Pulmonary embolism]]</div>}}
:❑ [[Pulmonary embolism]]</div>}}
{{ familytree | | | | | | |!| | | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{ familytree | | | | | | E01 | | | | | | | | | | | | | | | | |E01=<div style="text-align: center;  padding:1em;"> '''Focused bedside pre-test risk assessment'''</div><div style="float: left; text-align: left;  padding:1em;">
{{ familytree | | | | | | | E01 | | | | | | | | | | | | | | | |E01=<div style="text-align: center;  padding:1em;"> '''Focused bedside pre-test risk assessment'''</div><div style="float: left; text-align: left;  padding:1em;">
❑ ''High risk conditions''<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>
❑ ''High risk conditions''<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>
:❑ Marfan syndrome <br>
:❑ Marfan syndrome <br>
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:❑ Murmur of  aortic insufficiency <br>  
:❑ Murmur of  aortic insufficiency <br>  
:❑ Hypotension or shock <br>  </div>}}
:❑ Hypotension or shock <br>  </div>}}
{{ familytree | | | |,|-|-|^|-|-|-|-|-|v|-|-|-|-|-|-|.| | | }}
{{ familytree | | | |,|-|-|-|^|-|-|-|-|v|-|-|-|-|-|-|.| | | }}
{{ familytree | | |GRE | | | | | | |YEL | | | | |RED| | |GRE=<div style="text-align=center; width: 18em; padding:1em;">'''Low pre-test probability'''<br>(No features present)<br>''High threshold for aortic imaging''</div>
{{ familytree | | |GRE | | | | | | |YEL | | | | |RED| | |GRE=<div style="text-align=center; width: 18em; padding:1em;">'''Low pre-test probability'''<br>(No features present)<br>''High threshold for aortic imaging''</div>
|YEL=<div style="text-align=center; width: 18em; padding:1em;">'''Intermediate pre-test probability'''<br>(1 feature present)<br>''Intermediate threshold for aortic imaging''</div>
|YEL=<div style="text-align=center; width: 18em; padding:1em;">'''Intermediate pre-test probability'''<br>(1 feature present)<br>''Intermediate threshold for aortic imaging''</div>
|RED=<div style="text-align=center; width: 18em; padding:1em;">'''High pre-test probability'''<br>(2 or more features present) <br>''Immediate surgical evaluation and expedited aortic imaging''</div>
|RED=<div style="text-align=center; width: 18em; padding:1em;">'''High pre-test probability'''<br>(2 or more features present) <br>''Immediate surgical evaluation and expedited aortic imaging''</div>

Revision as of 13:53, 1 April 2015

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 managed 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

❑ 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?

❑ Hemodynamic instability:

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status
Oliguria

❑ High risk features
Presence of 2 or more high risk features, requires immediate surgical management.

Difference in the blood pressure in both extremities
❑ Signs of shock (hypoperfusion)
Pulse deficit involving carotid, femoral or subclavian arteries
Diastolic murmur suggestive of aortic regurgitation
Marfan's syndrome
❑ Signs suggestive of stroke
❑ Aortic disorder
Aortic valve disease
❑ Recent aortic manipulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the following things simultaneously

❑ Assess hemodynamic stability
❑ Order urgent TEE and look for the following features:

Pericardial effusion
❑ Regional wall motion abnormality (RWMA)
❑ Dilated root
Aortic regurgitation (AR)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Assess airway, breathing, and circulation
❑ Place a cardiac monitor to monitor cardiac rhythm
❑ Intra-arterial BP monitoring
❑ Secure 2 large-bore intravenous lines (IVs)
❑ Monitor oxygen, respiration, blood pressure, and urine output
❑ Frequently assess, hemodynamic compromise, mental status changes, neurologic or peripheral vascular changes
❑ Monitor development or progression of carotid, brachial, and femoral bruits
❑ Indwelling urethral catheter is used to monitor urine output
❑ Obtain blood samples for,

CBC, electrolytes
Cardiac enzymes to rule out MI
Blood group and cross match
 
Titrate BP between 90-120 mm Hg
❑ Control heart rate by betablockers before lowering BP by other agents, as other agents can lead to reflex tachycardia and worsening of aortic dissection
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
Metoprolol
❑ 5 mg intravenously every 5-10 minutes
❑ If necessary increase up to a maximum dosage of 15 mg/total dose

❑ Substitute non-dihydropyridine calcium channel blockers or vasodilators or labetalol if betablockers are contraindicated

Diltiazem
❑ 0.25 mg/kg intravenous bolus initially then 5-10 mg/hr infusion
❑ If necessary increase dose to 15 mg/hr
Verapamil
❑ 0.05 to 0.1 mg/kg IV bolus
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
Labetalol
❑ 1-5 mg/min IV infusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Can aortic dissection be confirmed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Type A dissection
 
Type B dissection
 
Obtain a secondary imaging study, if there is a high clinical suspicion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Transfer to a cardio-thoracic unit for the surgical management
 
❑ Initiate medical management unless there is
❑ Leaking of dissection
❑ Rupture of dissection
❑ Malperfusion to any organ
 
 
 
 
 
 
 
 
 
 
 

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:
❑ 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)

❑ HEENT examination

❑ 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)

❑ Cardiovascular examination

❑ 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]

❑ Respiratory examination

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)

❑ Abdominal examination

Ascites

❑ Neurological examination

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

❑ Extremity examination

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 Treatment

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
❑ Check whether dissection occurred in ascending aorta
 
Yes
 
Consider surgical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Start Medical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check Vitals
Blood pressure in both arms
❑ Take the highest reading for treatment or goal therapy
❑ Is patient hemodynamically stable ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Control rate and pressure
Beta blockers

Betablockers are contraindicated in hypersensitivity, bradycardia, heart block, uncompensated 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
Metoprolol
❑ 5 mg intravenously every 5-10 minutes
❑ If necessary increase up to a maximum dosage of 15 mg/total dose


OR
❑ Substitute non-dihydropyridine calcium channel blockers or vasodilators or labetalol if betablockers are contraindicated

Calcium channel blockers are contraindicated in hypersensitivity, 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
Verapamil
❑ 0.05 to 0.1 mg/kg IV bolus
Vasodilators
Nitroprusside

Nitroprusside is contraindicated in hypersensitivity, poor cerebral ischemia or coronary perfusion

❑ 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
Labetalol
❑ 1-5 mg/min IV infusion

❑ Goal heart rate should be 60 beats per minute
❑ Goal systolic BP 90-120 mm of Hg


❑ Pain control

❑ Use Opiates
Morphine sulphate
❑ 2-5 mg intravenously every 5-30 minutes or as needed
 
 
 
 
 
Type A dissection

❑ Is a surgical emergency, do an expedited surgical consultation
Surgery is relatively contraindicated in hemorrhagic stroke
❑ Maintain euvolemic status

❑ Intravenous fluid replacement
❑ Maintain mean arterial pressure (MAP) of 70 mm of Hg

❑ Rule out the following complications using imaging studies:

Pericardial tamponade
Rupture of aorta
Aortic insufficiency
Myocardial infarction
Stanford A type dissection
 
 
 
 
 
Type B dissection

❑ Uncomplicated dissection are treated medically

❑ Intravenous fluid replacement
❑ Maintain mean arterial pressure (MAP) of 70 mm of Hg
❑ Start vasopressors, if the patient remains hypotensive

❑ Complicated aortic dissection is treated surgically

❑ Leaking dissection
❑ Rupture
❑ Malperfusion to a vital organs
Refractory hypertension (decreased renal perfusion)
Tensed abdomen
❑ Progressive metabolic acidosis
❑ Increasing liver enzymes[17]
❑ Rupture in the pericardial sac(rare)
Beck's triad (cardiac tamponade)[18]

❑ Imaging studies to find out contained rupture

❑ Perform Transthoracic echocardiogram (TTE) to assess cardiac function
Stanford B type dissection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Can the cause of hypotension respond to surgical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Monitor vitals closely
❑ Maintain systolic BP <120 mm of Hg
 
No
 
 
 
 
 
Yes
 
Consider surgical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check if dissection involves ascending aorta
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Control blood pressure
❑ Intravenous vasodilator
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Monitor vitals closely
❑ Maintain systolic BP <120 mm of Hg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check for any complications which might require surgery

❑ Malperfusion
❑ Progressing dissection
❑ Expansion of aortic aneurysm
Uncontrolled or refractory hypertension
 
Yes
 
❑ Consider surgical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Switch to oral medications
Betablockers
Antihypertensive regimen

❑ 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Surgical Treatment

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.[9]

 
 
 
 
 
 
 
 
 
❑ Imaging study confirms aortic dissection
❑ Check whether dissection occurred in ascending aorta
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess suitability for surgery
❑ Patient stable for pre-op testing?
 
No
 
Medical management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Age > 40?
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess need for pre-operative coronary angiography
❑ Known CAD?
❑ Significant risk factors for CAD?
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform angiography
Is significant CAD detected on angiography?
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Plan for CABG at the time of aortic dissection repair
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform urgent operative management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform intra-operative assessment of aortic valve by Transesophageal echocardiography (TEE) for presence of one 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".
  18. "Acute Stanford type B dissection and cardiac... [Ann Thorac Surg. 2007] - PubMed - NCBI".
  19. "Predictors of complications in acute type B aortic dissection".

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