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First Initial Rapid Evaluation of Suspected Aortic Dissection

Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of Aortic dissection.

Confirmed aortic dissection ❑ Check whether dissection occurred in ascending aorta

Yes

Consider surgical management

No

❑ Start Medical management

❑ Check Vitals ❑ Blood pressure in both arms ❑ Take the highest reading for treatment or goal therapy ❑ Is patient hemodynamically stable ?

Yes

No

❑ Control rate and pressure ❑ I.V Beta blockers or labetalol ❑ Substitute diltiazem and verapamil If betablockers are contraindicated ❑ Goal Heart rate should be 60 beats per minute ❑ Pain control ❑ Use Opiates

❑ Type A dissection ❑ Expedited surgical consultation and consider surgery (Urgent) ❑ Maintain Euvolemic status ❑ Intravenous fluid replacement ❑ Maintain mean arterial pressure (MAP) of 70 mm of hg ❑ Rule out complications using imaging study ❑ Pericardial tamponade ❑ Rupture of aorta ❑ Aortic insufficiency

❑ Type B dissection ❑ Intravenous fluid replacement ❑ Maintain mean arterial pressure (MAP) of 70 mm of hg ❑ Start vasopressor if still hypotensive ❑ Find out etiology of hypertension ❑ Imaging to find out contained rupture ❑ Perform Transthoracic echocardiogram (TTE) to assess cardiac function ❑ Consider surgical evaluation

❑ Can the cause of hypotension respond to surgical management

❑ Monitor vitals closely ❑ Maintain systolic BP <120 mm of Hg

No

Yes

Consider surgical management

Yes

No

❑ Check whether dissection involves ascending aorta

Yes

No

❑ Control blood pressure ❑ Intravenous vasodilator

❑ Monitor vitals closely ❑ Maintain systolic BP <120 mm of Hg

❑ Check for any complications which might require surgery ❑ Malperfusion ❑ Progressing dissection ❑ Expansion of aortic aneurysm ❑ Uncontrolled or refractory hypertension

Yes

❑ Consider surgical management

No

❑ Switch to oral medications ❑ Betablockers ❑ Antihypertensive regimen ❑ Follow up in the outpatient

❑ Identify cardinal signs and symptoms that increase the pretest probability of acute aortic rupture

❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing) ❑ Asymmetric blood pressure in extremities ❑ Shock ❑ Pulse deficit ❑ Evolving aortic regurgitation murmur

Unstable patient

Stable patient

❑ Order urgent TTE ❑ Look for the following high risk features: ❑ Pericardial effusion ❑ Regional wall motion abnormality (RWMA) ❑ Dilated root ❑ Aortic regurgitation (AR)

Continue with diagnostic approach

❑ Aortic dissection confirmed ❑ Transfer to Cardio-thoracic unit ❑ Perform TEE in CCU or cardiac OR

❑ Proceed to surgery

Look for the following: Intimal flap and tear
Intimal entry
Mobile linear flap in short axis view
Small central true lumen communicating with false lumen