1 / 17

Aortic Dissection

Aortic Dissection. Tintinalli Chap. 63. Epidemiology. Male to Female (3:1) Mean age is 63 Incidence 3.5 per 100,000. Risk Factors. Systemic HTN (present in 70-90%) Connective Tissue disorders (Ehlers-Danlos; Marfan ’ s; Lupus; Giant Cell Arteritis; Cystic Medial Necrosis)

airell
Download Presentation

Aortic Dissection

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Aortic Dissection Tintinalli Chap. 63

  2. Epidemiology • Male to Female (3:1) • Mean age is 63 • Incidence 3.5 per 100,000

  3. Risk Factors • Systemic HTN (present in 70-90%) • Connective Tissue disorders (Ehlers-Danlos; Marfan’s; Lupus; Giant Cell Arteritis; Cystic Medial Necrosis) • Pregnancy (3rd Trimester) • Congenital Heart Disease (bicuspid aortic valve; coarctation) • Turner’s • 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 • >75% 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 (>8cm) (63%) • Change in the aortic formation • Loss of A/P window • Eggshell sign: Extension of aortic shadow >3mm 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. myweb.lsbu.ac.uk/dirt/museum/679-659.html www.mudphudder.com/2008/11/aortic-dissection/ 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. 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

More Related