Aortic dissection resident survival guide: Difference between revisions
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❑ Respiratory examination | ❑ Respiratory examination | ||
: ❑ Crackles/crepitations/rales | : ❑ [[Crackles]] / [[crepitations]] / [[rales]] | ||
: ❑ Decreased movement of the chest on affected side | : ❑ Decreased movement of the chest on affected side | ||
: ❑ Stony dullness to percussion | : ❑ Stony dullness to percussion | ||
: ❑ Diminished breaths sounds | : ❑ Diminished breaths sounds | ||
: ❑ Decreased vocal resonance and fremitus | : ❑ Decreased [[vocal resonance]] and fremitus | ||
: ❑ Pleural friction rub. | : ❑ [[Pleural friction rub]]. | ||
❑ Abdominal examination: | ❑ Abdominal examination: | ||
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: ❑ [[Peptic ulcer disease]] or perforating ulcer | : ❑ [[Peptic ulcer disease]] or perforating ulcer | ||
: ❑ [[Acute pancreatitis]] | : ❑ [[Acute pancreatitis]] | ||
: ❑ [[Esophageal perforation | : ❑ [[Esophageal perforation]] rupture | ||
: ❑ Musculoskeletal pain | : ❑ [[Musculoskeletal pain]] | ||
: ❑ Mediastinal tumors | : ❑ [[Mediastinal tumors]] | ||
{{familytree | | | | | | | | |!| | | | | |}} | {{familytree | | | | | | | | |!| | | | | |}} | ||
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Revision as of 00:45, 10 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]
Definition
A tear in the layers of the aorta especially in the intima leading to bleeding and separation of the layers of the aorta from within which creates a false lumen. Aortic dissction can be further defined as:
- Acute dissection- Dissection occurring within 2 weeks of onset of pain
- Subacute dissection-Dissection occurring witin 2-6 weeks of onset of pain
- Chronic dissection- Dissection occurring within 6 weeks of pain.
Classification
Aortic dissection can be classified into four types. DeBakey and Daily (Stanford) systems are the commonly used systems used to classify aortic dissection.[1][2][3][4]
- Stanford system classifies dissection into the following two types based on whether ascending aorta is involved or not.
- Ascending aortic dissection or type A
- All other dissections or type B
- DeBakey system classifies dissection according to location of the tear.
- Type I- Starts at ascending aorta and extension upto the aortic arch
- Type II- Starts and is limited till the ascending aorta
- Type III- Starts in the descending aorta and progresses proximally or distally
- Type III A - Restricted till the descending thoracic aorta
- Type III B - Dissection extending below the diaphragm
- The third type of classification divides aortic dissection according to the proximity
- Proximal- Ascending aortic involvement
- Distal- Descending aortic involvement distal to left subclavian artery
Causes
Life Threatening Causes
Aortic dissection is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Atherosclerosis
- Complication of cardiac procedures
- Chest trauma
- Connective tissue disorders
- Hypertension
- Vasculitis[5]
Management
Obtain a detailed history:
❑ Past medical history
❑ Family history
- ❑ Aortic disorder*
- ❑ Connective tissue disorder*
❑ Anatomic deformities
- ❑ Aortic valve disease*
- ❑ Thoracic aortic aneurysm*
- ❑ Coarctation of aorta
- ❑ Polycystic kidney disease
❑ Iatrogenic
- ❑ Recent aortic manipulation*
- ❑ Chronic steroid usage
- ❑ Immunosuppressive therapy
❑ Lifestyle
- ❑ Cocaine abuse
- ❑ Heavy weight lifting
❑ Trauma
❑ Genetic
- ❑ Marfan's syndrome*
- ❑ Ehlers-Danlos syndrome
- ❑ Turners syndrome
- ❑ Biscuspid aortic valve
- ❑ Loeys-Dietz syndrome
- ❑ Familial thoracic aneurysm and dissection syndrome
❑ Inflammatory vasculitis
❑ Pregnancy
❑ Infections involving the aorta }} {{familytree | | | | | | | | B01 | | | |B01=❑ General examination:
- ❑ Pulse rate - ↑
- ❑ Blood pressure - ↑ or ↓
- ❑ Respiratory rate - ↑
- ❑ Wide pulse pressure
- ❑ Difference in the blood pressure in both extremities*
- ❑ Increased sweating or anhidrosis
- ❑ Signs of shock (hypoperfusion)*
- ❑ Pulse deficit involving carotid, femoral or subclavian arteries*
❑ Head/neck examination:
- ❑ ↑ JVP
- ❑ Signs of vocal cord paralysis
- ❑ Pemberton's sign (SVC)
- ❑ Venous distention in the neck and distended veins in the upper chest and arms (SVC)
❑ Cardiovascular examination:
- ❑ Diastolic murmur suggestive of aortic regurgitation*
- ❑ Wheeze (cardiac asthma) (CHF)
- ❑ Pericardial friction rub
❑ Respiratory examination
- ❑ Crackles / crepitations / rales
- ❑ Decreased movement of the chest on affected side
- ❑ Stony dullness to percussion
- ❑ Diminished breaths sounds
- ❑ Decreased vocal resonance and fremitus
- ❑ Pleural friction rub.
❑ Abdominal examination:
- ❑ Ascites
- ❑ Claudication of buttocks
- ❑ Absent femoral pulses
❑ Neurological examination:
- ❑ Altered mental status*
- ❑ Signs of peripheral neuropathy
- ❑ Signs of stroke*
❑ Extremity examination:
- ❑ Pedal edema
❑ Ophthalmological examination
❑ Assess the severity by counting the high risk features marked in bold and by *
❑ Consider close differential diagnoses:
- ❑ Myocardial infarction due to an acute coronary syndrome with or without ST segment elevation
- ❑ Aortic regurgitation without dissection
- ❑ Aortic aneurysm without dissection
- ❑ Pericarditis
- ❑ Atherosclerotic or cholesterol embolism
- ❑ Pulmonary embolus
- ❑ Pleuritis
- ❑ Cholecystitis
- ❑ Peptic ulcer disease or perforating ulcer
- ❑ Acute pancreatitis
- ❑ Esophageal perforation rupture
- ❑ Musculoskeletal pain
- ❑ Mediastinal tumors
Characterize the symptoms: ❑ Cardiac
❑ Extra cardiac
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Do's
Dont's
References
- ↑ Nienaber, CA.; Eagle, KA. (2003). "Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies". Circulation. 108 (5): 628–35. doi:10.1161/01.CIR.0000087009.16755.E4. PMID 12900496. Unknown parameter
|month=
ignored (help) - ↑ Tsai, TT.; Nienaber, CA.; Eagle, KA. (2005). "Acute aortic syndromes". Circulation. 112 (24): 3802–13. doi:10.1161/CIRCULATIONAHA.105.534198. PMID 16344407. Unknown parameter
|month=
ignored (help) - ↑ DEBAKEY, ME.; HENLY, WS.; COOLEY, DA.; MORRIS, GC.; CRAWFORD, ES.; BEALL, AC. (1965). "SURGICAL MANAGEMENT OF DISSECTING ANEURYSMS OF THE AORTA". J Thorac Cardiovasc Surg. 49: 130–49. PMID 14261867. Unknown parameter
|month=
ignored (help) - ↑ Daily, PO.; Trueblood, HW.; Stinson, EB.; Wuerflein, RD.; Shumway, NE. (1970). "Management of acute aortic dissections". Ann Thorac Surg. 10 (3): 237–47. PMID 5458238. Unknown parameter
|month=
ignored (help) - ↑ "Classification of diabetic retinopathy from fluorescein angiograms. ETDRS report number 11. Early Treatment Diabetic Retinopathy Study Research Group". Ophthalmology. 98 (5 Suppl): 807–22. 1991. PMID 2062514.