Aortic Emergencies: True Jeopardy

1. Aortic Emergencies:True Jeopardy Meira Louis Dr Adam Oster

3. Ouch, my Back! 10 pts What are type A and type B dissections and what percentage of dissections account for each?

5. 62% 38%

6. Ouch, my Back! 20 pts Name five indications for a surgical approach

7. When Surgery? Surgical mortality: 27% Medical mortality: 56% • All Type A • Type B if: • Persistent pain • Uncontrollable hypertension • Occlusion of a major artery or branch point • Frank leak or rupture • Development of an anurysm Surgical mortality: 32% Medical mortality: 10%

8. Type A repair

9. Ouch, my Back! 30 pts What is pseudohypotension

10. When the intimal flap obstructs the flow to one or more limbs, giving low blood pressure peripherally, but adequate central pressure

11. Signs and Symptoms • Blood Pressure • Type A 36%, Type B 70% • Sudden severe sharp chest pain - 73% • Type A – anterior pain • Type B – back or abdominal pain • Syncope – 13% of Type A • Abdominal pain • Type A 22%, Type B 43% • Aortic insufficiency murmur • Type A 44%, Type B 12% • Pulse Deficits – less than 30%

12. Demographics • Under 40 • More likely to present without HTN • More likely to have a bicuspid aortic valve or have had prior aortic valve surgery

13. Peak time of day - 8-9am Peak time of year – Winter (October-January) Mehta et al. IRAD investigators. Circulation. 2002; 106(9):1110-1115.

14. Ouch, my Back! 40 pts What two parameters are you targeting with medical management, and what two drugs would you use to help get you there?

15. Goal One: dP/dT • Beta blockers to get your heart rate under 60 • Esmolol • 5g in 500ml of D5W • Bolus 500µg/kg, then infuse • Labetolol • 20mg IV bolus q5-10 minutes • Then infuse at 1-2µg/min • If history of bronchospasm/COPD can use β only (metoprolol)

16. Goal Two: Blood Pressure • Want to reduce the afterload • Sodium Nitroprusside • Dont use: • Nifedipine • Can increase shear stress on wall • Nitroglycerine • Less effective than nitroprusside

17. Long Term

18. Fat Pipes 10 points At what size does a thoracic aortic aneurysm greatly increase its likelihood of rupture?

19. Rates and Measurement

20. Hinge Points

21. AAA

22. Fat Pipes 20 points DAILY DOUBLE

23. What is the name of this condition and what causes it?

24. Blue Toe Syndrome • Microemboli of cholesterol crystals or clot • Palpable pedal pulses and cool, cyanotic toe

25. Palpable Mass

26. Fat Pipes 30 points What is the sensitivity of ED ultrasound for detecting abdominal aortic aneurysms?

27. Overall: • 73 studies reviewed • 4 studies included • All used convenience samples of symptomatic patients • Sensitivity 94-100% • Specificity: 98-100% • No differences by level of training

28. Fat Pipes 40 points For an asymptomatic patient with AAA of 4.2cm, does the evidence support any interventions, other than imaging follow up?

30. Evolving Research • Statins – Schouten et al, 2006 • ACE inhibitors – Hackam et al, 2006 • ARBs – Mochizuki et al, 2007 • Antibiotic agents - Mosorin et al, 2001

31. In real life... 10 points • 76yo female with 45 minutes of pain radiating to the back • Chronic HTN, dyslipidemia, osteoarthritis • BP 161/95, HR 117 • Bedside U/S is suspicious for a ruptured AAA What ED management would you undertake?

32. Ruptured AAA management • Two large bore IVs • Crossmatched blood (massive transfusion) • BP management • Permissive hypotension • Need to prevent end-organ damage • MI, resp failure, renal failure in post-op period • NO evidence that lowering HTN helps • Surgery

33. In real life... 20 points • A 72 yo male presented with acute onset of bilateral lower limb ischemia • Creatinine was elevated at 340 • Hb was stable at 154, no evidence of a GI bleed

34. Aortocaval Fistula • Abdominal or back pain • Continuous abdo. bruit (75%) • Palpable abdominal thrill (25%) • High Output CHF signs • Dyspnea • Jugular venous distension • Pulmonary edema

35. Aortocaval Fistula • Dilated superficial veins on legs and abdominal wall • Venous rupture in GI and bladder • Gross hematuria • Rectal bleeding • Renal insufficiency

36. In real life... 30 points • 43 yo male with history of alcohol abuse • Bright red emesis and melena • BP 80/20, HR 120/min • No meds, no surgical hx, no prior GI bleeds • Normal INR/PTT, platelets • Endoscopy showed clots, but no source of bleeding

37. Aorto-enteric Fistula • Third or Fourth segment of the duodenum • Primary vs Secondary • First stage • Leaking GI contents, abscess • Second Stage • Erosion of vessels in bowel wall • Third Stage • Rupture into GI lumen

38. In real life... 40 points • 72yo male presents with vague , dull abdominal pain • Intermittent abdominal bruit can be heard • BP 115/85, HR 72 • Underwent successful Dacron endovascular AAA repair 1 month ago • History of controlled HTN, diabetes, CAD What must be ruled out?

39. Endoleaks

40. Aortic Pics 10 points Who is this man and what did he die from?

41. John Ritter • Collapsed on set in 2003 and died the same day • Widow sued his radiologist and cardiologist • "Both sides agree that his true condition -- an aortic dissection, which is a tear in the largest blood vessel in the body -- was not identified until right before his death.“

42. Aortic Pics 20 pts Name the following sign:

43. Chest Film • widening aortic knob- widening of mediastinum • widening of descending aorta • widening of ascending aorta • parasternal shadow widening • pleural effusion • tracheal shift • blurring of aortic knob • localising lump on aortic arch distal to great vessels • displacement of intimal calcification >6 mm

44. CT

45. Other Modalities • TTE • TEE • MRI

46. Aortic Pics 30 points On the morning of 25 October 1760, this man entered his water closet and, after a few minutes, his valet heard a loud crash. The valet entered the water closet to find him on the floor. He was lifted into his bed, and asked for his daughter, but before she reached him, he was dead.

47. William III • George II • Adam I • Henry VI

48. King George II of England Died of a Thoracic Aortic Dissection

49. Aortic Pics 40 points DAILY DOUBLE

50. A 69-year-old white male scientist consulted his physician because of pain in the upper abdomen. For a number of years he had suffered from attacks of upper abdominal pain, which usually lasted for 2-3 days and were often accompanied by vomiting. These attacks usually occurred about every 3 or 4 months. • The patient was a pipe smoker and slightly overweight. The rest of his history was noncontributory. On physical examination, his physician noted a pulsating mass deep in the center of the abdomen. Which famous scientist died of a ruptured aortic aneurysm?