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Aortic dissection

Aortic dissection. Peter Cheng. irad. 12 referral centres 646 patients 1996 -1998. Aortic dissection. Wide clinical spectrum Chest pain most common 72.7% Tearing/ripping were not characteristic descriptors Abrupt onset 84.8% and severe 90.6% Migrating 16.6%

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Aortic dissection

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  1. Aortic dissection Peter Cheng

  2. irad • 12 referral centres • 646 patients • 1996 -1998

  3. Aortic dissection • Wide clinical spectrum • Chest pain most common 72.7% • Tearing/ripping were not characteristic descriptors • Abrupt onset 84.8% and severe 90.6% • Migrating 16.6% • Abdo pain 29% Back pain 53% • Syncope 9.4% • No other neuro deficits • Hypertension 70% Type B, 35.7% Type A • Hypotension = tamponade UPO • Aortic regurg murmur in half • ECG normal in 31%

  4. CXR • CXR findings • Mediastinalwidening • Left paraspinalstripe • Displacement of intimal calcifications (calcium sign) • Apical pleural cap • Left pleural effusion • Displacement of endotracheal tube or nasogastric tube • 63% sensitive for widened mediastinum • Completely normal in 12.4%

  5. US • Limited role as a bedside test except to rule out pericardial tamponade • Aortic regurg (doppler) • Intimal flap may be seen using parasternal and suprasternal view • Transoesophageal (TOE) very sensitive but less accessible than CT

  6. treatment • Overall mortality 27.4% • Type A • Surgery reduces mortality from 58% to 26% • Type B • Surgery worsens prognosis from 10 – 31%!! • Majority successfully managed medically • BP control • Reduced wall stress • Beta-blocker egesmolol aiming for 60bpm / systolic 120mmHg +/- IV antiHT • Fentanyl 25-50mcg • Urgent transfer to CTS

  7. AD VS AMI • Due to dissection of R or L coronary arteries • Needs robust discussion with Cardiologist • Poor eGFR must not hinder emergent CT aortogram • Hypotension • Tamponade • Myocardial ischaemia • Aortic insufficiency • Withhold thrombolytics/heparin

  8. Always … • Palpate bilateral radial pulses • Measure bilateral BPs

  9. http://emcrit.org/podcasts/aortic-dissection/

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