Surg - Aortic Dissection

Question 1

Classify Dissections

Answer 1

StanfordDeBakeyEuropean Society of Cardiology

Question 2

Describe the Stanford

Answer 2

Types A and BA - involves ascending aortaB - descending only distal to origin of left subclavian artery

Question 3

Describe DeBakey

Answer 3

I - ascending and propogates to the aortic archii - acending onlyiii - originates in descendingiiia - limited to thoracic aortaiiib - extends below diaphragm

Question 4

Risk factors for dissection

Answer 4

Advanced AgeHypertensionMaleSmokerFamily historyPregnancyTrauma (decel injury)Congenital (Marfans, Ehlers, co-arctation, Turners)

Question 5

Features of a dissection

Answer 5

A - sudden onset chest pain extending into the backB - back pain aloneDifferential/Absent pulses or delays in the extremitiesAortic regurgSyncope - impaired cerebral flow Stroke or other neurology

Question 6

Complications of a dissection

Answer 6

CVS - Myocardial ischaemia           Tampanade            Acute aortic regurg            Hypertension            Hypotension/shock  (due to tampondae or blood loss or coronary dissection)

Neuro - ischaemic stroke paraplegia - spinal cord hypoperfusionPulm - effusions (left)Renal (AKI)Haem - Coagulopathy and transfusion needGI - mesenteric ischaemia

Question 7

Types of imaging

Answer 7

CXR - wide mediastinum effusion - cardiomegaly calcified aortic knuckleTTE - may see intimal flap, aortic regurg, assess cardiac functionTOE - identify true and false lumensCT - extent of flap, enable surgical planMRI - confirms and reveals extentAortography - not done but was gold standard (needs contrast, takes a long time)

Question 8

Principles of management

Answer 8

ABCDE etc.GoalsTreat hypertensionConfirm dissectionEstablish need for surgery

i. initial actionsO2large bore cannular, FBC, U&E, Clotting, xmatch 6 units, venous gas, trop)Art lineCatheterECGAnalgesiaManage hypotension - volume aiming for systolic of 100mmhFind aeotiology, involve surgeons

Question 9

Hypertension management in dissection

Answer 9

Low SBP to 100-120 MAP 60-65Reduce shear force but no reflex tachy (b-blockers - esmolol/labet)Vasodilators GTN, SNP2nd line - CCB