Aortic dissection resident survival guide: Difference between revisions
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==Management== | ==Management== | ||
{{familytree/start}} | |||
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:'''<br> | |||
❑ Cardiac | |||
: ❑ '''Chest pain described as <br>tearing, ripping, sharp or stabbing<sup>*</sup>''' | |||
: ❑ '''Abrupt onset of pain and <br>increasing in intensity<sup>*</sup>''' | |||
: ❑ Chest pain worsened by deep breathing or cough and <br> relieved by sitting upright | |||
: ❑ [[Anxiety]] | |||
: ❑ [[Palpitation]] | |||
: ❑ Fainting | |||
: ❑ Sweating | |||
: ❑ Pale skin | |||
: ❑ Rapid, weak pulse | |||
: ❑ Shortness of breath | |||
: ❑ [[Peripheral edema]] | |||
: ❑ Rapid breathing | |||
: ❑ [[Orthopnea]] | |||
❑ Extra cardiac | |||
: ❑ Abdominal pain or back pain | |||
: ❑ Flank pain | |||
: ❑ Lower and upper extremity weakness, numbness and tingling | |||
: ❑ Nausea and vomiting | |||
: ❑ Symptoms suggestive of stroke | |||
: ❑ Swallowing difficulties due to pressure on the esophagus | |||
: ❑ [[Gastrointestinal bleeding]] | |||
: ❑ [[Altered mental status]] | |||
: ❑ Feeling of impending doom | |||
: ❑ [[Hemoptysis]] | |||
: ❑ [[Drooping of eyelids]] | |||
: ❑ Decreased or no sweating | |||
: ❑ [[Haematemesis]] | |||
: ❑ [[Hoarseness of voice]]</div>}} | |||
---- | |||
'''Obtain a detailed history:'''<br> | |||
❑ Past medical history | |||
: ❑ [[Hypertension]] | |||
: ❑ [[Pheochromocytoma ]] | |||
❑ Family history | |||
: ❑ '''Aortic disorder<sup>*</sup>''' | |||
: ❑ '''[[Connective tissue disorder]]<sup>*</sup>''' | |||
❑ Anatomic deformities | |||
: ❑ '''Aortic valve disease<sup>*</sup>''' | |||
: ❑ '''[[Thoracic aortic aneurysm]]<sup>*</sup>''' | |||
: ❑ [[Coarctation of aorta]] | |||
: ❑ [[Polycystic kidney disease]] | |||
❑ Iatrogenic | |||
: ❑ '''Recent aortic manipulation<sup>*</sup>''' | |||
: ❑ Chronic steroid usage | |||
: ❑ Immunosuppressive therapy | |||
❑ Lifestyle | |||
: ❑ [[Cocaine]] abuse | |||
: ❑ Heavy weight lifting | |||
❑ Trauma | |||
❑ Genetic | |||
: ❑ '''[[Marfan's syndrome]]<sup>*</sup>''' | |||
: ❑ [[Ehlers-Danlos syndrome]] | |||
: ❑ [[Turners syndrome]] | |||
: ❑ [[Biscuspid aortic valve]] | |||
: ❑ [[Loeys-Dietz syndrome]] | |||
: ❑ Familial thoracic aneurysm and dissection syndrome | |||
❑ Inflammatory vasculitis | |||
: ❑ [[Takayasu arteritis]] | |||
: ❑ [[Giant cell arteritis]] | |||
: ❑ [[Behcet's arteritis]] | |||
❑ Pregnancy | |||
❑ Infections involving the aorta </div>}} | |||
{{familytree | | | | | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''<br> | |||
❑ General examination: | |||
: ❑ Pulse rate - ↑ | |||
: ❑ Blood pressure - ↑ or ↓ | |||
: ❑ Respiratory rate - ↑ | |||
: ❑ [[Wide pulse pressure]] | |||
: ❑ '''Difference in the blood pressure in both extremities<sup>*</sup>''' | |||
: ❑ Increased sweating or [[anhidrosis]] | |||
: ❑ '''Signs of [[shock]] (hypoperfusion)<sup>*</sup>''' | |||
: ❑ '''Pulse deficit involving carotid, femoral or subclavian arteries<sup>*</sup>''' | |||
❑ 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]]<sup>*</sup>''' | |||
: ❑ [[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]]<sup>*</sup>''' | |||
: ❑ Signs of [[peripheral neuropathy]] | |||
: ❑ '''[[Signs of stroke]]<sup>*</sup>''' | |||
❑ Extremity examination: | |||
: ❑ Pedal edema | |||
❑ Ophthalmological examination | |||
: ❑ [[Miosis]] | |||
: ❑ [[Ptosis]] | |||
❑ 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 | |||
{{familytree | | | | | | | | |!| | | | | |}} | |||
{{familytree/end}} | |||
==Do's== | ==Do's== |
Revision as of 18:08, 7 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
| |||||||||||||||||||||||||||||
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.