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{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | A01 |-| A02 |-| A03 | | | | |}}
{{familytree | | | | | | | | | | | | A01 |-| A02 |-| A03 | | | | |A01=<div style="float: left; text-align: left; padding:1em">'''Confirmed aortic dissection''' <br> ❑ Check whether dissection occurred in ascending aorta </div>|A02=Yes |A03=Consider surgical management}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01=No}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em">❑ Start Medical management </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em">❑ Check Vitals <br>
:❑ Blood pressure in both arms <br>
:❑ Take the highest reading for treatment or goal therapy <br>
❑ Is patient hemodynamically stable ?</div> }}
{{familytree | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}}
{{familytree | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}}
{{familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | |}}
{{familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | |E01=Yes |E02=No}}
{{familytree | | | | | | | | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}}
{{familytree | | | | | | | | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}}
{{familytree | | | | | | | | F01 | | | | | | F02 | | | | | | F03 |}}
{{familytree | | | | | | | | F01 | | | | | | F02 | | | | | | F03 |F01=<div style="float: left; text-align: left; padding:1em">❑ Control rate and pressure<br>
: ❑ I.V [[Beta blockers]] or [[labetalol]]
: ❑ Substitute [[diltiazem]] and [[verapamil]]<br> If [[betablockers]] are contraindicated
----
❑ Goal Heart rate should be 60 beats per minute
----
❑ Pain control<br>
: ❑ Use [[Opiates]]</div> |F02=<div style="float: left; text-align: left; padding:1em"> ❑ '''Type A dissection'''
----
❑ Expedited surgical consultation and consider surgery (Urgent)<br>
❑ Maintain Euvolemic status<br>
: ❑ Intravenous fluid replacement<br>
:❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of hg<br>
❑ Rule out complications using imaging study<br>
: ❑ [[Cardiac tamponade|Pericardial tamponade]]
: ❑ [[Aortic rupture|Rupture of aorta]]<br>
: ❑ [[Aortic insufficiency]]</div>|F03=<div style="float: left; text-align: left; padding:1em">❑ Type B dissection
----
❑ Intravenous fluid replacement<br>
: ❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of hg<br>
❑ Start vasopressor if still hypotensive
----
❑ Find out etiology of hypertension
:❑ Imaging to find out contained rupture
:❑ Perform [[Echocardiography|Transthoracic echocardiogram (TTE)]] to assess cardiac function
----
❑ Consider surgical evaluation</div> }}
{{familytree | | | | | | | | |!| | | | | | | |!| | | | | | | |!| |}}
{{familytree | | | | | | | | |!| | | | | | | |!| | | | | | | |!| |}}
{{familytree | | | | | | | | |!| | | | | | | G01 | | | | | | |!| |}}
{{familytree | | | | | | | | |!| | | | | | | G01 | | | | | | |!| |G01=<div style="float: left; text-align: left; padding:1em">❑ Can the cause of hypotension respond to surgical management</div>}}
{{familytree | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| |}}
{{familytree | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| |}}
{{familytree | | | | | | | | H01 |-| H02 | | | | | | H03 |-| H04 |}}
{{familytree | | | | | | | | H01 |-| H02 | | | | | | H03 |-| H04 |H01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely
: ❑ Maintain systolic BP <120 mm of Hg</div> |H02=No |H03=Yes |H04=Consider surgical management}}
{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
{{familytree | | | | I01 | | | | | | I02 | | | | | | | | | | | | |}}
{{familytree | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01=Yes |I02=No}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | J01 | | | | | | J02 | | | | |}}
{{familytree | | | | |!| | | | | | | J01 |-|-|-|-|-| J02 | | | | |J01=<div style="float: left; text-align: left; padding:1em"> ❑ Check whether dissection involves ascending aorta</div> |J02=Yes}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |!| | | | | | | K01 | | | | | | |!| | | | | |}}
{{familytree | | | | |!| | | | | | | K01 | | | | | | |!| | | | | |K01=No}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
{{familytree | | | | |`|-|-| L01 |-|-|'| | | | | | | |!| | | | | |}}
{{familytree | | | | |`|-|-| L01 |-|-|'| | | | | | | |!| | | | | |L01=<div style="float: left; text-align: left; padding:1em">❑ Control blood pressure
: ❑ Intravenous vasodilator</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | M01 | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | M01 | | | | | | | | | | |!| | | | | |M01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely
: ❑ Maintain systolic BP <120 mm of Hg</div>}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | N01 |-| N02 |-| N03 |-|-|'| | | | | |}}
{{familytree | | | | | | | | N01 |-| N02 |-| N03 |-|-|'| | | | | |N01=<div style="float: left; text-align: left; padding:1em">❑ Check for any complications which might require surgery
----
: ❑ Malperfusion
: ❑ Progressing dissection
: ❑ Expansion of aortic aneurysm
: ❑ [[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 | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | O01 | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | O01 | | | | | | | | | | | | | | | | |O01=No}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | P01 | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | P01 | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; padding:1em">❑ Switch to oral medications <br>
:❑ [[Betablockers]]
:❑ Antihypertensive regimen
----
❑ Follow up in the outpatient</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
==FIRE==
 
==First Initial Rapid Evaluation of Suspected Aortic Dissection==
Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of Aortic dissection.
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01=Suspected aortic dissection }}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01=❑ Identify cardinal signs and symptoms that increase the pretest probability of acute aortic rupture }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | B01 | | | | | | | | | | |B01=<div style="text-align: left">❑ Look for the following cardinal signs & symptoms: <br>
{{familytree | | | | | | | | | | B01 | | | | | | | | | | |B01=<div style="text-align: left">❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing)<br>
:❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing)<br>
❑ Asymmetric blood pressure in extremities<br>
:❑ Asymmetric blood pressure in extremities<br>
❑ Shock <br>
:❑ Shock <br>
❑ Pulse deficit <br>
:❑ Pulse deficit <br>
❑ Evolving aortic regurgitation murmur </div>}}
:❑ Evolving aortic regurgitation murmur </div>}}
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | }}
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | }}
{{familytree | | | | | | C01 | | | | | | C02 | | | | | | |C01=<div style=" background: #F60A0A"> {{fontcolor|#F8F8FF|Unstable patient}} </div>|C02=Stable patient }}
{{familytree | | | | | | C01 | | | | | | C02 | | | | | | |C01=<div style=" background: #F60A0A"> {{fontcolor|#F8F8FF|Unstable patient}} </div>|C02=Stable patient }}
Line 49: Line 91:
:❑ Regional wall motion abnormality (RWMA) <br>
:❑ Regional wall motion abnormality (RWMA) <br>
:❑ Dilated root <br>
:❑ Dilated root <br>
:❑ Aortic regurgitation (AR)}} </div>  |D02=Continue with diagnostic approach }}
:❑ Aortic regurgitation (AR)}} </div>  |D02=[[Aortic dissection resident survival guide#Diagnosis|Continue with diagnostic approach]] }}
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | }}
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | }}
{{familytree | | | | | | E01 | | | | | | | | | | | | | | |E01=<div style=" background: #F60A0A; text-align: left"> {{fontcolor|#F8F8FF|❑ Aortic dissection confirmed  
{{familytree | | | | | | E01 | | | | | | | | | | | | | | |E01=<div style=" background: #F60A0A; text-align: left"> {{fontcolor|#F8F8FF|❑ Aortic dissection confirmed  

Latest revision as of 22:25, 1 April 2014

First Initial Rapid Evaluation of Suspected Aortic Dissection

Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of Aortic dissection.

 
 
 
 
 
 
 
 
 
 
 
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
❑ I.V Beta blockers or labetalol
❑ Substitute diltiazem and verapamil
If betablockers are contraindicated

❑ Goal Heart rate should be 60 beats per minute


❑ Pain control

❑ Use Opiates
 
 
 
 
 
Type A dissection

❑ Expedited surgical consultation and consider surgery (Urgent)
❑ Maintain Euvolemic status

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

❑ Rule out complications using imaging study

Pericardial tamponade
Rupture of aorta
Aortic insufficiency
 
 
 
 
 
❑ Type B dissection

❑ Intravenous fluid replacement

❑ Maintain mean arterial pressure (MAP) of 70 mm of hg

❑ Start vasopressor if still hypotensive


❑ Find out etiology of hypertension

❑ Imaging to find out contained rupture
❑ Perform Transthoracic echocardiogram (TTE) to assess cardiac function

❑ Consider surgical evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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 whether 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Identify cardinal signs and symptoms that increase the pretest probability of acute aortic rupture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing)

❑ Asymmetric blood pressure in extremities
❑ Shock
❑ Pulse deficit

❑ Evolving aortic regurgitation murmur
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient
 
 
 
 
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Order urgent TTE
❑ Look for the following high risk features:
❑ Pericardial effusion
❑ Regional wall motion abnormality (RWMA)
❑ Dilated root
❑ Aortic regurgitation (AR)
 
 
 
 
 
Continue with diagnostic approach
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Aortic dissection confirmed

❑ Transfer to Cardio-thoracic unit

❑ Perform TEE in CCU or cardiac OR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed to surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Look for the following: Intimal flap and tear
Intimal entry
Mobile linear flap in short axis view
Small central true lumen communicating with false lumen