aortic dissection
DESCRIPTION
Case presentation and brief review aortic dissectionTRANSCRIPT
Aortic dissection
Case presentation
50 yo man BIBA at 0230 with 3 hours of dull non-radiating central chest pain.
En route, administered O2, 300mg Aspirin, 10mg Morphine and 10mg Metoclopramide
Pain free on arrival.
Previously well
No positive risk factors for IHD or PE
No regular medication or other drug
use
No trauma or recent infections
No prior episodes of chest pain
Vomited twice at home, and described as clammy and pale on arrival of ambulance, with BP 90/60 supine.
On arrival
Pale
Temp 37 HR 60
BP 60/40mmHg RR 14
O2 sat100% (3L/min)
GCS 15/15
Equal radial pulses4/6 Systolic murmurLungs clear to auscultation
ECG
Initial treatment
IV fluid 1L Normal saline statColour improved, BP to 90/60 mmHg, Pain free
Early investigations:Trop T < 3 ng/L (N < 15)
Course
2nd ECG normal and Trop T < 3 at 6 hours post onset of pain
2nd litre of saline running, BP still 90/60mm/Hg, HR 60/min, with normal peripheral perfusion
BP both arms the sameChest pain “2/10”
Decision to order CT angiogram of chest
Intimal tear / flap of dissection in aortic arch
7.10AM Patient transferred to the OT for repair of the type A dissection and the aneurysmal dilatation of aortic root.
Aortic Dissection
Relatively uncommon (2.6-3.3/100 000 person- years)
Initial event in aortic dissection is a tear in the aortic intima.
Propagation of the
dissection may be
1. Proximal (retrograde)
2. Distal (antegrade)
Complications
Aortic valve injury with regurgitation
Pericaridal tamponade
End organ ischemia, examples include syncope, CVA, mesenteric or renal ischaemia.
Risk factors for aortic dissection
Advancing ageMale sex 2:1 (Female – pregnancy)Systemic hypertensionPre-existing aortic aneurysmAtherosclerosis
Risk factors for under age 40
Collagen vascular disorders VasculitisBicuspid aortic valveAortic coarctationTurners syndromeMarfan syndrome Prior aortic valve surgeryInstrumentationTraumaHigh intensity weight lifting or other exerciseCocaine
Classification
Stanford Type A –ascending AortaType B – all other types / sites in aorta
DeBakeyType I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally.
Type II – Originates / confined to the ascending aorta.
Type III – Originates in descending aorta, rarely extends proximally but will extend distally.
Diagnosis
Routine bloods – non diagnostic D-dimer < 500ng/ml unlikely to be dissection
History Anterior chest pain in ascending aortic
dissection Severe sharp or tearing posterior chest or
back pain when the dissection progresses distal to the subclavian artery
Pain can associated with
Syncope Stroke MIHeart failureEnd organ ischemia (splanchnic, renal, extremity or spinal cord ischaemia)
Hypertension common with type BHypotension
Diagnosis of aortic dissection depends
upon demonstration of the dissection on
imaging studies
CXRCTMRITEE / TTE
CT
Immediate management
Maintain airway, good supportive careTreat hypotension / hypertension – aim for MAP 60-70
Beta blockerseg esmalol propranolol, labetalol
Vasodilators Na nitroprussideCalcium channel blockerseg verapamil, diltiazem
Management
Type A – Surgical
Type B – Surgical/medical