Dissecting Aneurysm

1
Dissecting Aneurysm

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• Wang, Tzong-Luen,MD, PhD, FACC, FESC

2
ECHO for Chest Pain

• Indications for Echocardiography in Patients With
  Chest Pain 
• 1. Diagnosis of underlying cardiac disease in
  patients with chest pain and clinical evidence of
  valvular, pericardial, or primary myocardial
  disease. I
• 2. Evaluation of chest pain in patients with
  suspected acute myocardial ischemia, when
  baseline ECG is nondiagnostic and when study can
  be obtained during pain or soon after its
  abatement. I
• 3. Evaluation of chest pain in patients with
  suspected aortic dissection. I
• 4. Chest pain in patients with severe hemodynamic
  instability. I
• 5. Evaluation of chest pain for which a
  noncardiac etiology is apparent. III
• 6. Diagnosis of chest pain in a patient with
  electrocardiographic changes diagnostic of
  myocardial ischemia/infarction. III

3
Epidemiology

• Proximal almost twice as often as distal
• Incidence 5 per million per year
• Overall mortality rate 20-25
• Hemorrhage and acute heart failure
• Late complication in survivors rupture of
  postdissection anurysm
• 10-20
• More likely if uncontrolled hypertension

4
Risk Factors

• Inflammatory Diseases of the Aorta
• Syphilitic aortitis
• Polyarteritis nodosa
• Endocarditis
• Mycotic infections of the aorta
• Giant cell aortitis
• SLE
• Pregnancy
• Arteriosclerosis
• Cigarette use

• Hypertension
• Congenital Diseases
• Bicuspid aortic valve
• Congenital aortic stenosis
• Coarctation of aorta
• Cystic medial necrosis
• Congenital Disorders of Connective Tissue
• Marfans syndrome
• Ehlers-Danlos syndrome

5
Clinical Manifestations

• Cardiovascular
• Chest Pain (80-90)
• Severe steady pain
• Sudden onset
• Retrosternal if type A
• Interscapular if type B
• Migrate to chest, back and epigastrium
• Hypertension (60-70)
• Hypotension
• AR murmur (50 type A)
• Pericardial friction rub (5)

• General
• Hoarseness
• Syncope

6
Clinical Manifestations

• Gastrointestinal
• Abdominal or lumbar pain
• Nausea
• Vomiting

• Extremities
• Extremity weakness or paralysis
• Peripheral pulse deficits (40-50)

7
Complications

• Cardiac tamponade
• Myocardial infarction
• CHF
• Hemothorax
• Predominantly left
• Hemoperitoneum

• Hemispheric stroke
• 6 of cases
• Altered mental status
• Temporary blindness
• Ischemic myopathy
• Intestinal ischemia
• Renal or lower limb ischemia

8
ECG

• Changes compatible with MI 10-20
• Positive ECG dose not exclude Dx
• ST elevation is unusual
• Negative ECG
• supporting

• Signs of preexisting hypertension
• LVH
• LV strain
• Pericarditic changes
• Diffuse ST elevation
• PR depression
• Electrical alternans

9
Pulmonary Embolism

• ??? ??
• Wang, Tzong-Luen,MD, PhD, FACC, FESC

10
Clinical Presentation

• SIGNS and SYMPTOMS
• Most common
• Dyspnea
• Pleuritic chest pain
• Tachycardia
• General
• Apprehension
• Diaphoresis

11
Clinical Presentation

• SIGNS and SYMPTOMS
• Pulmonary
• Cough
• Hemoptysis
• Rales
• Wheezing
• Cardiovascular
• syncope
• Loud P2
• S3 or S4 gallop
• Diaphoresis
• Cardiac murmures

12
Clinical Presentation

• SIGNS and SYMPTOMS
• Cyanosis
• Extremities
• Evidence of thrombophlebitis
• Lower extremity edema

13
Clinical Presentation

• Mechanism / Description
• Vast majority arise from thrombi in the deep
  veins of the femur and pelvis
• Thrombi in the lower extremities occasionally
  propagate to the popliteal veins from where they
  embolize

14
Clinical Presentation

• Etiology
• Most patients with pulmonary embolus(PE) have an
  identifiable risk factor

15
Clinical Presentation

• Etiology
• Risk factors
• Recent surgery
• Pregnancy
• Cardiac disease
• Stroke or recent paraplegia
• Malignancy
• Age past the fifth decade
• Previous DVT
• Immobilization
• Oral contraceptives
• Major trauma
• Factor deficiency state
• Mutations in factor 5 resulting in activated
  protein C resistance
• Protein C and S
• Plasminogen and antithrombin 3 deficiency
• Antiphospholipid antibody syndrome

16
Clinical Presentation

• Pediatric Considerations
• Risk factors for children in decreasing order
  of prevalence
• Presence of central venous catheter
• Immobility
• Heart disease
• Ventriculoatrial shunt
• Trauma
• Neoplasm
• Surgery
• Infection
• Medical Illness
• Dehydration
• Shock

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Pre-Hospital

• Cautions
• Initiate supplemental oxygen
• Establish IV access
• Cardiac monitor

18
Diagnosis

• Essential workup
• CXR
• To rule out other causes
• Most common findings with PE
• Normal
• Nonspecific pulmonary infiltrates
• Atelectasis
• Other findings with PE
• Pleural effusions
• Pleural based opacities (When wedged shaped
  called Hampton hump)
• Elevated hemidiaphragms
• Local oligemia (Westermarks sign)
• Enlarged right descending pulmonary artery
  (Pallas sign)

19
Diagnosis

• ECG
• To rule out a cardiac etiology
• Findings in PE
• Nonspecific ST-T wave changes
• T-wave inversion in anterior leads
• Sinus tachycardia
• Normal ECG
• Left axis deviation
• RBBBpattern
• Atrial fibrillation
• S1Q3T3 pattern-uncommon and not specific enough
  to rule-in diagnosis of PE

20
Diagnosis

• ECG
• Assess oxygenation
• Pulse oximetry
• Rapidly attained
• Arterial blood gases
• Assesses pO2 and pCO2
• Do not aid in the diagnosis
• PE possible with normal Alveolar-arterial gradient

21
Diagnosis

• Laboratory
• CBC
• Anemia may be a contributing factor to dyspnea
• Very high WBC might suggest infectious etiology
• d-dimer enzyme-linked immunosorbent assay (ELISA)
• High sensitivity with low specificity for PE
• High negative predictive value (gt90)
• Requires 3-4 hours to perform

22
Diagnosis

• Imaging / Special tests
• Ventilation perfusion (V/Q) scan
• Results reported in probabilities normal, low,
  intermediate, or high probability

23
Diagnosis

• Imaging / Special tests
• Ventilation perfusion (V/Q) scan
• Probability of PE with V/Q results
• Normal or near normal V/Q scan 4 probability
  for PE
• Low probability V/Q scan with low clinical
  suspicion 4 probability for a PE
• Low probability V/Q scan with high clinical
  suspicion 16-40 probability for a PE
• Intermediate V/Q scan 16-66 probability of PE
• High probability V/Q scan with low clinical
  suspicion 56 probability of PE
• High probability V/Q scan with high clinical
  suspicion 96 probability of PE

24
Diagnosis

• Imaging / Special tests
• Spiral chest CT with IV contrast
• Accurate for identifying PE in proximal pulmonary
  vascular tree
• May be normal with small distal PE
• Pulmonary angiography
• Gold standard
• Use when diagnosis not excluded or confirmed
• Intermediate probability (10-80) VQ scan
• Normal CT when distal PE suspected
• Higher complication rate than other modalities
• Lower extremity duplex ultrasound
• Used in patients who would otherwise require
  pulmonary angiography
• Presence of deep vein thrombosis requires same
  anticlagulation as PE

25
Diagnosis

• Differential Diagnosis
• Pneumonia
• Cardiac dysrhythmias (due to syncope)
• Asthma
• Pneumothorax
• Pleural effusion
• Pericarditis
• Myocardial infarction
• Rib fracture
• Musculoskeletal pain
• Pulmonary edema

26
Treatment

• Initial Stabilization
• ABCs
• Provide supplemental oxygen to maintain adequate
  oxygen saturation with nasal cannula or face mask
• Intubation for if unable to provide adequate
  oxygen
• Administer IV fluid carefully for hypotensive
  patients
• Excessive fluid expansion may worsen right heart
  failure

27
Treatment

• ED Treatment
• Initiate heparin
• Prevents additional thrombus from forming
• Goal is to maintain the PTT between 1.5 and 2.5
  times the control value (60-80 seconds)

28
Treatment

• ED Treatment
• Warfarin
• Begin once a therapeutic PTTis achieved
• Continue for 5 days with concurrent heparin
  administration
• Goal is INR of 2-3
• Thrombolysis
• Initiate in hemodynamically unstable patients
  with massive PE
• Stop heparin while infusing TPA
• Restart heparin when PTT falls in therapeutic
  range (1.5-2.5 times control)

29
Treatment

• ED Treatment
• Inferior vena cava (IVC) filter
• Indicated in patients who cannot tolerate
  anticoagulation and who have been on therapeutic
  anticoagulation but failed
• Norepinephrine
• Initiate whith massive PE and hypotension

30
Treatment

• Medications
• Heparin options
• Initial bolus of 80 units/kg IV followed by
  continuous infusion of 18 units/kg/hr
• Initial bolus of 5,000 units IV followed by 1,280
  units/hr
• TPA 100 mg IV over 2 hrs
• Norepinephrine 2-20 µg/min IV
• Coumadin 5mg loading dose orally each day,
  titrate PT to an INR 2-3

31
Treatment

• Pediatric Considerations
• Heparin dosing 50 IU/kg bolus IV followed by
  10-25 IU/kg/hr continuously
• Thrombolytic dosing
• TPA 0.1-0.5 mg/kg body weight per hour (use for
  as long as 3days)
• TPA is not approved by the FDA for use in
  children
• Streptokinase 3,500-4,000 IU/kg loading dose
  over 30 min followed by 1,000-1,500 IU/kg/hr
• Urokinase 4,400 IU/kg loading dose over 10 min
  followed by 4,400 IU/kg/hr

32
Disposition

• Admission Criteria
• Admit all patients with PE for heparin therapy
• Cases with a high suspicion for PE, no
  contraindication to anticoagulatoin, and a lack
  of V/Q scanning or angiographic availability may
  be anticoagulated and studied when resources are
  available in the morning or upon transfer
• Discharge Criteria
• N/A

33
Miscellaneous

• ICD 415.1
• Core content code 16.9

34
Miscellaneous

• Suggested readings
• ACCP Consensus Committee on Pulmonary
  Embolism. Opinions regarding the diagnosis and
  management of venous thromboembolic disease.
  Chest 1996109233-37.
• Becker DM,, Philbrick JT, Bachhuber TL,
  Humphries JE. D-dimer testing and acute venous
  thromboembolism. Arch Intern Med 1996156939-46
• Evans DA, Wilmott RW. Pulmonary embolism in
  children. Pediatr Clin North Am 199441569-84

35
Miscellaneous

• Suggested readings
• Ginsburg JS. Management of venous
  thromboembolism. N Engl J Med 19963351816-28
• Goldhaber SZ. Pulmonary embolism. N Engl J
  Med 199933993-104
• PIOPED Investigators. Value of the ventilation
  / perfusion scan in acute pulmonary embolism.
  JAMA 19902632753-59.
• Trukstra F, Kuijer PM, Van Beek EJ, et al.
  Diagnostic utility of ultrasonography o f leg
  veins in patient suspected of having pulmonary
  embolism. Ann Intern Med 1997126775-81.
• Author Richard Lenhardt