Ouch My chest hurts Maybe my back too

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Ouch! My chest hurts! Maybe my back too!
Bryan Barrus, MS III Penn State University
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HP

• M.S. a 73 yo male presents with chest pain that
  is mid-sternal, radiates to jaw, severe
  diaphoresis, dyspnea, back pain. Pt had cardiac
  stent placed 2 weeks ago. EMS gave 3 nitros with
  minimal effect. No fever, nausea, vomiting,
  rashes. PMH cardiomyopathy, CAD, mitral
  insufficiency, rheumatic fever, CHF, diabetes,
  descending thoracic aneurysm, COPD, smoker.

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• CXR 4/22/08

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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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CT w/ contrast 4/22/08
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Genesis
PMH cardiomyopathy, CAD, mitral insufficiency,
rheumatic fever, CHF, diabetes, descending
thoracic aneurysm, COPD, smoker
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Classification
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Aortic dissection

• Frequency 1 in 10,000
• Etiology HTN, aneurysm, iatrogenic,
  atherosclerosis, congenital valve anomalies,
  Marfan syndrome, advanced age, pregnancy,
  Ehlers-Danlos, syphilis, trauma, aortic arch
  hypoplasia, cocaine
• Mortality 10-15 with 10 having severe
  neurological defects

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Treatment

• Medical
• Decrease contractility B-blockers
• Decrease systemic BP nitroprusside, Ca channel
  blockers, labetalol
• Insert A-line, Swan-Ganz, Foley cath
• Surgery
• Definitive treatment
• Contraindications CVA, severe LV dysfunction,
  coagulopathy, pregnancy, post MI (lt6 mo),
  significant arrhythmias, advanced age, severe
  valvular disease

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References

• Emedicine.com aortic dissection 4/29/08
• Wikipedia.com (images) aortic dissection 4/29/08