Sandbox/00006

FIRE: Focused Initial Rapid Evaluation

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

Abbreviations: AVR: Aortic valve replacement; 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 onset ❑ Tearing or sharp quality ❑ Increasing in intensity ❑ Syncope ❑ Perfusion deficits ❑ Refractory hypertension (decreased renal perfusion) ❑ Tensed abdomen ❑ Progressive metabolic acidosis ❑ Increasing liver enzymes

Assess the severity by the high risk features and hemodynamic instability ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status

High risk features includes If 2 or more high risk features are present, aortic dissection is confirmed by TEE and requires immediate surgical management. High risk features are as follows ❑ Chest pain described (tearing, ripping, sharp or stabbing) ❑ Sudden onset of pain and increasing in intensity ❑ Aortic disorder ❑ Aortic valve disease ❑ Recent aortic manipulation ❑ 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

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)

Continue with the diagnostic approach below

Does the patient have hypotension

Yes

No

❑ Assess airway, breathing, and circulation ❑ Place a cardiac monitor ❑ 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 it leads 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 ❑ 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

Consider the following contraindications before prescribing :❑ Betablockers ❑ Hypersensitivity ❑ Bradycardia ❑ Heart block ❑ Uncompensated heart failure ❑ Hypotension ❑ Asthma ❑ Severe chronic obstructive pulmonary disease ❑ Calcium channel blockers ❑ Hypersensitivity ❑ Hypotension ❑ Second- or third-degree atrioventricular block ❑ Sick sinus syndrome ❑ Left ventricular dysfunction ❑ Pulmonary congestion ❑ Nitroprusside ❑ Hypersensitivity ❑ Poor cerebral or coronary perfusion

Is aortic dissection confirmed?

Yes

No

❑ Transfer to a cardio-thoracic unit for the surgical management

Obtain a secondary imaging study, if there is a high clinical suspicion