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Aortic dissection (Risk factors (HTN, Bicuspid aortic valve, CT disorder …
Aortic dissection
Risk factors
HTN
Bicuspid aortic valve
CT disorder
(Marfan's, Ehler's-Danlos)
Recent heart surgery
(cardiac surgery, angioplasty)
Pathophysiology
Longitudinal splitting of muscular
aortic media by a column of blood
Spread
Proximal
Coronary artery blockage
Cardiac tamponade
Aortic incompetence
Neurological signs
(carotid or spinal arteries)
Distal
Disrupting origin of
several arteries
Rupture
Internally
(into aorta)
Externally
(mediastinum)
Clinical presentation
Chest pain
Radiation
If it migrates
Associated symptoms
Syncope
Character
Tearing/ripping
Timing
Constant
Exacerbating/relieving factors
Difficult to alleviate, even with IV opioid
Severity
Severe
Onset
Sudden
Site
Central/posterior chest
Syncope
Neurological signs (rare)
Diagnosis
Examination
Cardio exam
Tachycardia, radial-radial delay, radiofemoral delay,
quiet heart sounds, pericardial rub, murmur (AR)
Neuro exam
May have neuro signs depending
on spread (carotid, spinal)
Investigations
Bloods
ABG, FBC, CRP, U+E, troponins,
amylase, glucose, lipids, clotting,
group&save, crossmatch 6u
Imaging
CXR: Widened mediastinum, Double knuckle aorta,
L pleural effusion, R tracheal deviation, separation of
walls of a calcified aorta (Ca sign)
ECHO: definitive diagnosis
CT angiography: definitive diagnosis
Bedside
Obs (low sats, tachypnoea, tachycardia, low BP)
ECG (MI, LVH, ischemic changes)
History
PC/HPC
Chest pain, SOB, synope
PMH
CVD, CT disease
Previous surgery
DH
Current meds, allergies
FH
Cardiac disease, CT disease
SH
Living arragements, occupation,
smoking, alcohol
Classification
(Stanford)
Type A
Ascending aorta involved
(35% mortality)
Type B
Ascending aorta not involved
(15% mortality)
Management
Initial (ABCDE)
Definitive
Medical
Analgesia
IV morphine 10 mg + anti-emetic e.g. cyclizine
Inotropes/vasopressin
May be needed to control BP
Surgical
Surgical repair
ASAP
Conservative
Referral ASAP to cardiology, cardiothoracics
Referral to ITU (inotropic support)
Monitoring (arterial line)
Definition
Longitudinal splitting of muscular
aortic media by a column of blood