3.1 Aortic Dissection

Question 1

Sharp Intense Chest pain and Tachycardia

DDx

Answer 1

Cardaic

1. Aortic Dissection
2. MI
3. Myocarditis
4. Pericarditis
5. AR

Respiratory

1. PE
2. Pneumonia
3. Spont PTX
4. Pleurisy

MSK

1. Acute mechanic back pain
2. Costochondritis

GI

1. Oes spasm
2. Oes rupture
3. Severe reflux
4. Acute pancreatitis
5. Obstructed / incarcerated epigastric hernia

Question 2

Outline imagine modalities if Dissection suspected

Answer 2

CXR

TOE

CT

MRI

Aortography

Question 3

CXR

Answer 3

Aortic knuckle

• may be obvious separation calcified intima
• Widened mediastinum
• Cardiomegaly
• Blunting costophrenic angle 2* haemothorax

Question 4

TTE

Answer 4

Rapid and portable
Visualization of intimal flap in some cases

Provides dynamic information
-cardiac function
-aid assessment of patient
presence and severity of AR

Windows may be inadequate to exclude diagnosis
Especially trauma
obesity
COPD
severe calcified arterial disease

Results Operator dependent

Question 5

CT

Answer 5

Cross sectional imaging
Contrast enhancement allow diagnosis confirmed
3D recon
better surgical planning for repair

Provides info about extent of flap
none about presence + severity AR

Relative quick / Non invasive
caution HD unstable

Question 6

MRI

Answer 6

Excellent imaging quality
Slow acquire images
Unsuitable - unstable
Avoids contrast

Can assess presence AR

Requires specialist monitor / equipment magnet

C/I PM / Clips

Question 7

Aortography

Answer 7

Historically gold standard

good viz dissection flap
false lumen
origin branch arteries

Invasive
Contrast
Slow

Question 8

Management prior to transfer to CT centre

Initial

Answer 8

ABC structures approach
IV access fluid resus

Invasive monitoring
A line b-b BP
Serial ABG measure

Central access
infusion vasoactive

Bloods
FBC / U+E / Clotting
G+S / Troponin

Question 9

Management prior to transfer

Answer 9

Collateral detailed medical history
ID suitability + Desire surgery
significant comorb

Fluid resus
SBP adequate for organ perfusion
avoid over-resus

Endpoint SBP 100-110

Analgesia

Urinary Catheter + hourly bag

Question 10

Mx prior to transfer

BP

Answer 10

BP control
B block
First line - HR / Force contraction

Reduce shear force around origin dissection flap
- avoid tachycardia

Vasodilators
GTN / SNP short acting bp control

Ca++ channel antagonists
second line