Nontraumatic thoracic aortic dissection: Difference between revisions
(35 intermediate revisions by 8 users not shown) | |||
Line 1: | Line 1: | ||
''Not to be confused with [[traumatic aortic transection]]'' | ''Not to be confused with [[traumatic aortic transection]]'' | ||
==Background== | ==Background== | ||
[[File:Aorta segments.jpg|thumb|Aortic sebments.]] | |||
[[File:Aorta branches.jpg|thumb|Branches of the aorta.]] | |||
*Most commonly seen in men 60-80 yrs old | *Most commonly seen in men 60-80 yrs old | ||
*Intimal tear with blood leaking into media | *Intimal tear with blood leaking into media | ||
Line 9: | Line 10: | ||
**Young with risk factors | **Young with risk factors | ||
***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], Ehler's-Danlos, collagen vascular disease) | ***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], Ehler's-Danlos, collagen vascular disease) | ||
***Pregnancy, especially 3rd trimester | ***[[Pregnancy]], especially 3rd trimester | ||
***Recent cardiac catheterization | ***Recent cardiac catheterization | ||
***Bicuspid aortic valve | ***Bicuspid aortic valve | ||
***Aortic coarctation | ***[[coarctation of the Aorta|Aortic coarctation]] | ||
**Elderly males with chronic hypertension | **Elderly males with chronic hypertension | ||
**Atherosclerotic risk factors (smoking, hypertension, HLD, DM) | **Atherosclerotic risk factors (smoking, hypertension, HLD, DM) | ||
==Clinical Features== | ==Clinical Features== | ||
===General=== | ===General=== | ||
*Symptoms | *Symptoms | ||
**Tearing/ripping pain (10.8x increased disease probability) | **Tearing/ripping [[chest pain|pain]] (10.8x increased disease probability) | ||
***64% described the pain as sharp vs 50.6% who described it as tearing or ripping<ref>Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.</ref> | |||
**Migrating pain (7.6x) | **Migrating pain (7.6x) | ||
**Sudden chest pain (2.6x) | **Sudden chest pain (2.6x) | ||
**History of hypertension (1.5x) | **History of [[hypertension]] (1.5x) | ||
*Signs | *Signs | ||
**Focal neurologic deficit (33x) | **[[Focal neuro deficit|Focal neurologic deficit]] (33x) | ||
**Diastolic heart murmur (acute aortic regurg) (4.9x) | **Diastolic heart [[murmur]] (acute aortic regurg) (4.9x) | ||
**Pulse deficit (2.7x) | **Pulse deficit (2.7x) | ||
**Hypertension at time of presentation (49% of all cases<ref name="a">Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.</ref> | **[[Hypertension]] at time of presentation (49% of all cases<ref name="a">Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.</ref>) | ||
===Specific=== | ===Specific=== | ||
*Ascending Aorta | *Ascending Aorta | ||
**Acute [[aortic regurgitation]], leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66% | **Acute [[aortic regurgitation]], leading to a diastolic decrescendo [[murmur]], [[hypotension]], or [[heart failure]], in 50%-66% | ||
**[[MI]]/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery<ref>Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.</ref>) | **[[MI]]/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery<ref>Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.</ref>) | ||
**[[Cardiac Tamponade]] | **[[Cardiac Tamponade]] | ||
**[[Hemothorax]] - if adventitia disruption | **[[Hemothorax]] - if adventitia disruption | ||
**Horners, partial - sympathetic ganglion | **[[Horner syndrome|Horners]], partial - sympathetic ganglion | ||
**Voice hoarseness - recurrent laryngeal | **Voice hoarseness - recurrent laryngeal nerve compression | ||
**CVA/[[Syncope]] - if carotid extension | **[[CVA]]/[[Syncope]] - if carotid extension | ||
**Neurological deficits | **[[Focal neuro deficit|Neurological deficits]] | ||
**SBP>20mmhg difference between arms | **SBP>20mmhg difference between arms | ||
**Hypertension at time of presentation (35.7% of all cases<ref name="a"/>) | **[[Hypertension]] at time of presentation (35.7% of all cases<ref name="a"/>) | ||
*Descending Aorta | *Descending Aorta | ||
**[[Chest pain]], back pain, abdominal pain | **[[Chest pain]], [[back pain]], [[abdominal pain]] | ||
*** | ***Pain abrupt, severe (90% of patients) radiating to back | ||
**Hypertension at time of presentation (70.1% of all cases<ref name="a" />) | **[[Hypertension]] at time of presentation (70.1% of all cases<ref name="a" />) | ||
**Hemiplegia, neuropathy (15%) | **[[Weakness|Hemiplegia]], neuropathy (15%) | ||
**Renal failure | **[[Renal failure]] | ||
**Distal Pulse deficits/ [[limb ischemia]] | **Distal Pulse deficits/ [[limb ischemia]] | ||
**[[Mesenteric ischemia]] | **[[Mesenteric ischemia]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ | {{Chest Pain DDX}} | ||
{{Hypertension DDX}} | {{Hypertension DDX}} | ||
==Evaluation== | ==Evaluation== | ||
=== | ===[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs Aortic Dissection Detection Risk Score (ADD-RS)]=== | ||
''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features'' | ''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features'' | ||
{| class="wikitable" | {| class="wikitable" | ||
Line 97: | Line 65: | ||
|- | |- | ||
| | | | ||
*Marfan syndrome | *[[Marfan syndrome]] | ||
*Connective tissue disease | *[[Connective tissue disease]] | ||
*Family history of aortic disease | *Family history of aortic disease | ||
*Recent aortic manipulation | *Recent aortic manipulation | ||
Line 111: | Line 79: | ||
**Pulse deficit | **Pulse deficit | ||
**Systolic BP differential | **Systolic BP differential | ||
**Focal | **Focal neurological deficit (in conjunction with pain) | ||
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain) | *Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain) | ||
*[[Hypotension]] of shock state | *[[Hypotension]] of shock state | ||
Line 130: | Line 98: | ||
===No Risk Factor Screening=== | ===No Risk Factor Screening=== | ||
*[[CXR]] | *[[CXR]] | ||
**Abnormal in 90% | **Abnormal in 90% (3.4x) | ||
**Mediastinal widening (seen in 56-63%) | **Mediastinal widening (seen in 56-63%) | ||
**Left sided pleural effusion (seen in 19%) | **Left sided pleural effusion (seen in 19%) | ||
Line 136: | Line 104: | ||
[[File:Dissection CXR.jpg|thumbnail|CXR showing widened mediastinum and porminent aortic knob]] | [[File:Dissection CXR.jpg|thumbnail|CXR showing widened mediastinum and porminent aortic knob]] | ||
===Low-Intermediate (Based on | ===Low-Intermediate (Based on ADD-RS)<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>=== | ||
*[[D-dimer]] for ADD | *[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk) | ||
===High Risk/Definitive=== | ===High Risk/Definitive=== | ||
[[File:Dissection.png|thumbnail|CT chest with contrast of thoracic aortic dissection.]] | |||
*CT aortogram chest | *CT aortogram chest | ||
**Study of choice | **Study of choice | ||
**Similar sensitivity/specificity to TEE and MRA | **Similar sensitivity/specificity to TEE and MRA | ||
===Other Findings=== | ===Other Findings=== | ||
[[File:aorticdissection.gif|thumbnail|Type A Aortic Dissection<ref>http://www.thepocusatlas.com/echocardiography-1</ref>]] | |||
[[File:USDissection.png|thumbnail|Abdominal Aortic Dissection on Ultrasound]] | |||
*[[ECG]] | *[[ECG]] | ||
**[[LVH]] on admission ECG (3.2x) | |||
**Ischemia (esp inferior) - 15% | **Ischemia (esp inferior) - 15% | ||
**Nonspec ST-T changes - 40% | **Nonspec ST-T changes - 40% | ||
*Bedside US | *[[echocardiography|Bedside US]] | ||
**Can help in ruling in patients when AOFT is >4cm | **Can help in ruling in patients when AOFT is >4cm | ||
**Rule out pericardial effusion and tamponade | **Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea | ||
**TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref> | **TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref> | ||
[[File: | ===Classification (Stanford)=== | ||
*Type A | |||
**Involves any portion of ascending aorta | |||
*Type B | |||
**Isolated to descending aorta | |||
{| class="wikitable" | |||
|+Classification of aortic dissection | |||
|- style="background:white;" | |||
|valign="top"|'''Image''' | |||
|[[File:AoDissect DeBakey1.png|90px]] | |||
|[[File:AoDissect DeBakey2.png|90px]] | |||
|[[File:AoDissect DeBakey3.png|90px]] | |||
|- style="background:white;" | |||
||'''Percentage''' | |||
| style="text-align:center; "|60% | |||
| style="text-align:center; "|10–15% | |||
| style="text-align:center; "|25–30% | |||
|- style="background:white;" | |||
||'''Type''' | |||
| style="text-align:center;" border="0"|DeBakey I | |||
| style="text-align:center;"|DeBakey II | |||
| style="text-align:center;"|DeBakey III | |||
|- style="background:white;" | |||
||'''Classification''' | |||
| colspan=2 style="text-align:center;"|Stanford A (Proximal) | |||
| style="text-align:center;"|Stanford B (Distal) | |||
|- | |||
|} | |||
==Management== | ==Management== | ||
''Lower wall tension by lowering BP (La Place T = P × r)'' | ''Lower wall tension by lowering BP (La Place T = P × r)'' | ||
*Important considerations | *Important considerations | ||
**Right radial arterial line or right arm blood pressure will be the most accurate | **Right radial arterial line or right arm blood pressure will be the most accurate | ||
**Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension | **[[Beta blockers]] are good first-line options, since they reduce heart rate and aortic wall tension | ||
***However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo | ***However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo | ||
**It is important to provide adequate analgesia in order to decrease sympathetic output leading to tachycardia and hypertension | |||
#Heart rate control ([[beta-blockers]] are first line) | #Heart rate control ([[beta-blockers]] are first line) | ||
# | |||
# | ===Heart Rate control=== | ||
# | ;Control heart rate before blood pressure (Goal to keep HR <60 bpm and SBP 100-120)<ref>[https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.105.534198 Tsai TT, Nienaber CA, and Eagle KA. Acute Aortic Syndromes. Circulation. 2005;112:3802–3813]</ref> | ||
# | #[[Esmolol]] | ||
# | #*Advantage of short half life, easily titratable | ||
# | #*Bolus 0.5mg/kg over 1min; infuse 0.05mg/kg/min (titrate upward in 0.05mg/kg/min increments to a maximum of 0.3 mg/kg/min) | ||
# | #*[http://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf Esmolol Drip Sheet] | ||
# | #[[Labetalol]] - has both α and beta effects | ||
# | #*Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg | ||
# | #*Drip - Load 15-20mg IV, followed by 5mg/hr | ||
# | #[[Metoprolol]] | ||
#*5mg IV x 3; infuse at 2-5mg/hr | |||
#[[Diltiazem]] - Use if contraindications to beta-blockers | |||
#*Do not | #*Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h | ||
# | |||
# | ===Blood pressure control (vasodilators)=== | ||
# | #*Do not control blood pressure without adequate heart rate control (must suppress reflex tachycardia which will shear forces from increased HR) | ||
# | #[[Nicardipine]]/[[Clevidipine]] - consider following regimen for nicardipine: | ||
# | #*5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal | ||
# | #*Once at goal, drop to 3mg/hr and re-titrate from there | ||
#*May initially bolus 2mg IV<ref>Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf</ref> | |||
# | #[[Nitroprusside]] 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity | ||
#Analgesia | #[[Fenoldopam]] | ||
#[[Enalapril]] | |||
#[[Analgesia]] | |||
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output | #*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output | ||
===Surgery=== | |||
*Type A (any portion of ascending aorta) | |||
**Requires surgery | |||
*Type B (isolated to descending aorta) | |||
**Primarily medical management with surgery consultation | |||
==Disposition== | ==Disposition== | ||
Line 204: | Line 212: | ||
==See Also== | ==See Also== | ||
*[[Hypertensive emergency]] | |||
*[[Hypertensive | *[[Traumatic aortic transection]] | ||
*[[ | *[[Abdominal aortic aneurysm]] | ||
*[[Abdominal | |||
*[[IRAD]] | *[[IRAD]] | ||
Line 215: | Line 222: | ||
*[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary] | *[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary] | ||
*[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)] | *[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)] | ||
*[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs#evidence MDcalc ADD Score] | |||
==References== | ==References== |
Latest revision as of 21:51, 29 March 2022
Not to be confused with traumatic aortic transection
Background
- Most commonly seen in men 60-80 yrs old
- Intimal tear with blood leaking into media
- Mortality increases 1% per hour of symptoms when untreated
- Diagnosis delayed > 24hr in 50% of cases
- Bimodal age distribution
- Young with risk factors
- Connective tissue disease (e.g. Marfan syndrome, Ehler's-Danlos, collagen vascular disease)
- Pregnancy, especially 3rd trimester
- Recent cardiac catheterization
- Bicuspid aortic valve
- Aortic coarctation
- Elderly males with chronic hypertension
- Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
- Young with risk factors
Clinical Features
General
- Symptoms
- Tearing/ripping pain (10.8x increased disease probability)
- 64% described the pain as sharp vs 50.6% who described it as tearing or ripping[1]
- Migrating pain (7.6x)
- Sudden chest pain (2.6x)
- History of hypertension (1.5x)
- Tearing/ripping pain (10.8x increased disease probability)
- Signs
- Focal neurologic deficit (33x)
- Diastolic heart murmur (acute aortic regurg) (4.9x)
- Pulse deficit (2.7x)
- Hypertension at time of presentation (49% of all cases[2])
Specific
- Ascending Aorta
- Acute aortic regurgitation, leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%
- MI/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery[3])
- Cardiac Tamponade
- Hemothorax - if adventitia disruption
- Horners, partial - sympathetic ganglion
- Voice hoarseness - recurrent laryngeal nerve compression
- CVA/Syncope - if carotid extension
- Neurological deficits
- SBP>20mmhg difference between arms
- Hypertension at time of presentation (35.7% of all cases[2])
- Descending Aorta
- Chest pain, back pain, abdominal pain
- Pain abrupt, severe (90% of patients) radiating to back
- Hypertension at time of presentation (70.1% of all cases[2])
- Hemiplegia, neuropathy (15%)
- Renal failure
- Distal Pulse deficits/ limb ischemia
- Mesenteric ischemia
- Chest pain, back pain, abdominal pain
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Evaluation
Aortic Dissection Detection Risk Score (ADD-RS)
A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features
Predisposing conditions | Pain features | Physical findings |
|
Chest, back, or abdominal pain described as:
AND
|
|
Score | Category | Prevalence |
0 | Low | 6% |
1 | Intermediate | 27% |
>1 | High | 39% |
No Risk Factor Screening
- CXR
- Abnormal in 90% (3.4x)
- Mediastinal widening (seen in 56-63%)
- Left sided pleural effusion (seen in 19%)
- Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign
Low-Intermediate (Based on ADD-RS)[4][5][6]
- D-dimer for ADD-RS ≤ 1 (low or intermediate risk)
High Risk/Definitive
- CT aortogram chest
- Study of choice
- Similar sensitivity/specificity to TEE and MRA
Other Findings
- ECG
- LVH on admission ECG (3.2x)
- Ischemia (esp inferior) - 15%
- Nonspec ST-T changes - 40%
- Bedside US
- Can help in ruling in patients when AOFT is >4cm
- Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea
- TEE has a sensitivity of 98% and 95% specific[8]
Classification (Stanford)
- Type A
- Involves any portion of ascending aorta
- Type B
- Isolated to descending aorta
Image | |||
Percentage | 60% | 10–15% | 25–30% |
Type | DeBakey I | DeBakey II | DeBakey III |
Classification | Stanford A (Proximal) | Stanford B (Distal) |
Management
Lower wall tension by lowering BP (La Place T = P × r)
- Important considerations
- Right radial arterial line or right arm blood pressure will be the most accurate
- Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
- However, avoid β-blockers in aortic regurgitation murmurs or on bedside echo
- It is important to provide adequate analgesia in order to decrease sympathetic output leading to tachycardia and hypertension
- Heart rate control (beta-blockers are first line)
Heart Rate control
- Control heart rate before blood pressure (Goal to keep HR <60 bpm and SBP 100-120)[9]
- Esmolol
- Advantage of short half life, easily titratable
- Bolus 0.5mg/kg over 1min; infuse 0.05mg/kg/min (titrate upward in 0.05mg/kg/min increments to a maximum of 0.3 mg/kg/min)
- Esmolol Drip Sheet
- Labetalol - has both α and beta effects
- Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
- Drip - Load 15-20mg IV, followed by 5mg/hr
- Metoprolol
- 5mg IV x 3; infuse at 2-5mg/hr
- Diltiazem - Use if contraindications to beta-blockers
- Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
Blood pressure control (vasodilators)
- Do not control blood pressure without adequate heart rate control (must suppress reflex tachycardia which will shear forces from increased HR)
- Nicardipine/Clevidipine - consider following regimen for nicardipine:
- 5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
- Once at goal, drop to 3mg/hr and re-titrate from there
- May initially bolus 2mg IV[10]
- Nitroprusside 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
- Fenoldopam
- Enalapril
- Analgesia
Surgery
- Type A (any portion of ascending aorta)
- Requires surgery
- Type B (isolated to descending aorta)
- Primarily medical management with surgery consultation
Disposition
- Admission to OR or ICU
Complications
- AV Regurgitation/Insufficiency
- CHF with diastolic murmur
- Rupture
- Pericardium: cardiac tamponade
- Mediastinum: hemothorax
- Vascular obstruction
See Also
External Links
- NNT Aortic Dissection LRs
- AHA Full Guidelines
- AHA Quick Summary
- ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)
- MDcalc ADD Score
References
- ↑ Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.
- ↑ 2.0 2.1 2.2 Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.
- ↑ Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.
- ↑ Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.
- ↑ Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.
- ↑ Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.
- ↑ http://www.thepocusatlas.com/echocardiography-1
- ↑ Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.
- ↑ Tsai TT, Nienaber CA, and Eagle KA. Acute Aortic Syndromes. Circulation. 2005;112:3802–3813
- ↑ Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf