Aortic Dissection

1
Aortic Dissection

• Tintinalli Chap. 63

2
Epidemiology

• Male to Female (31)
• Mean age is 63
• Incidence 3.5 per 100,000

3
Risk Factors

• Systemic HTN (present in 70-90)
• Connective Tissue disorders (Ehlers-Danlos
  Marfans Lupus Giant Cell Arteritis Cystic
  Medial Necrosis)
• Pregnancy (3rd Trimester)
• Congenital Heart Disease (bicuspid aortic valve
  coarctation)
• Turners
• Trauma
• Aortic Valve Stenosis
• ID Syphilis, endocarditis
• Drug Tobacco Cocaine Methamphetamines

4
Pathophysiology

• Intimal tear that allows blood to leak through
  the media and adventitia
• Propagation depends on BP and the pulse wave
  (rate of change in pressure/time)
• High BP and rapid ventricular contractions
  further migration

5
Natural History

• If untreated
• 33 die within 24 hours
• 50 die within 48 hours
• gt75 die within 2 weeks
• 90 die within 3 months

6
Classification

• Debakey
• Type I ascending aorta part of distal aorta
• Type II ascending aorta only
• Type III descending aorta only
• IIIa extension limited to diaphragm
• IIIb continuation beyond diaphragm
• Stanford
• Type A ascending aorta (Debakey I II)
• Type B descending aorta (Debakey III)

7
Clinical Presentation

• Pain most common symptom usually aburpt,
  tearing/ripping, migrating, and maximal at onset
• Pain neurologic symptoms think dissection
• Syncope (9) decreased LOC (20) Paraplegia
  (5) Monoplegia (6) Vision changes (2)
• Physical Exam
• 49 have absent or decreased pulses distal to
  dissection
• Difference in BP (20mmHg between upper
  extremities or 30mmHg between upper and lower
  extremities)
• 20 have new murmur (aortic insufficiency)
• Signs of cardiac tamponade (Becks)

8
Diagnosis

• Chest Xray normal in 11
• Mediastinal widening (gt8cm) (63)
• Change in the aortic formation
• Loss of A/P window
• Eggshell sign Extension of aortic shadow gt3mm
  beyond calcified aortic wall
• Blurred aortic knob
• Lt. Pleural effusion (19)
• Double Density sign of the aorta
• ECG
• 20 showed evidence of ischemia
• Varying AV blocks
• Signs of LVH

9
Diagnosis

10
Diagnosis

• Transesophageal Echocardiography
• Sensitivity specificity nearly 100
• Can confirm diagnosis, define intimal tear site,
  aortic regurgitation, pericardial effusion, does
  not require IV contrast, performed in ED
• Disadvantage not readily available in all EDs
• CT
• Almost 100 sensitivity and specificity
• Can confirm the diagnosis, define the extent of
  dissection, and distinguish between Type A and
  Type B
• Disadvantage patient leaves ED, requires IV
  contrast

11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
Treatment

• All patients require 10-15 units of blood on
  stand-by and immediate thoracic surgery
  consultation
• All initial treatment is medical
• Decrease pulse rate and BP
• Goal is systolic 100-120 mmHg HR 50-60
• Esmolol gtts Nitroprusside combination
• Labetolol single agent
• IV narcotics
• Ascending require medical stabilization then
  surgery
• Descending require medical stabilization
  monitoring