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| {{familytree | | | | | | | | | | | | A01 |-| A02 |-| A03 | | | | |A01=<div style="float: left; text-align: left; padding:1em">'''Confirmed aortic dissection''' <br> ❑ Check whether dissection occurred in ascending aorta </div>|A02=Yes |A03=Consider surgical management}}
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| {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01=N0}}
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| {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em">❑ Start Medical management </div>}}
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| {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em">❑ Check Vitals <br>
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| :❑ Blood pressure in both arms <br>
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| :❑ Take the highest reading for treatment or goal therapy <br>
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| ❑ Is patient hemodynamically stable ?</div> }}
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| {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}}
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| {{familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | |E01=Yes |E02=No}}
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| {{familytree | | | | | | | | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}}
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| {{familytree | | | | | | | | F01 | | | | | | F02 | | | | | | F03 |F01=<div style="float: left; text-align: left; padding:1em">❑ Control rate and pressure<br>
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| : ❑ I.V [[Beta blockers]] or [[labetalol]]
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| : ❑ Substitute [[diltiazem]] and [[verapamil]]<br> If [[betablockers]] are contraindicated
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| ----
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| ❑ Goal Heart rate should be 60 beats per minute
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| ----
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| ❑ Pain control<br>
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| : ❑ Use [[Opiates]]</div> |F02=<div style="float: left; text-align: left; padding:1em"> ❑ '''Type A dissection'''
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| ----
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| ❑ Expedited surgical consultation and consider surgery (Urgent)<br>
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| ❑ Maintain Euvolemic status<br>
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| : ❑ Intravenous fluid replacement<br>
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| :❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of hg<br>
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| ❑ Rule out complications using imaging study<br>
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| : ❑ [[Cardiac tamponade|Pericardial tamponade]]
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| : ❑ [[Aortic rupture|Rupture of aorta]]<br>
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| : ❑ [[Aortic insufficiency]]</div>|F03=<div style="float: left; text-align: left; padding:1em">❑ Type B dissection
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| ----
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| ❑ Intravenous fluid replacement<br>
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| : ❑ Maintain [[mean arterial pressure|mean arterial pressure (MAP)]] of 70 mm of hg<br>
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| ❑ Start vasopressor if still hypotensive
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| ----
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| ❑ Find out etiology of hypertension
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| :❑ Imaging to find out contained rupture
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| :❑ Perform [[Echocardiography|Transthoracic echocardiogram (TTE)]] to assess cardiac function
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| ----
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| ❑ Consider surgical evaluation</div> }}
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| {{familytree | | | | | | | | |!| | | | | | | |!| | | | | | | |!| |}}
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| {{familytree | | | | | | | | |!| | | | | | | G01 | | | | | | |!| |G01=<div style="float: left; text-align: left; padding:1em">❑ Can the cause of hypotension respond to surgical management</div>}}
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| {{familytree | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| |}}
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| {{familytree | | | | | | | | H01 |-| H02 | | | | | | H03 |-| H04 |H01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely
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| : ❑ Maintain systolic BP <120 mm of Hg</div> |H02=No |H03=Yes |H04=Consider surgical management}}
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| {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}}
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| {{familytree | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01=Yes |I02=No}}
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| {{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}}
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| {{familytree | | | | |!| | | | | | | J01 |-|-|-|-|-| J02 | | | | |J01=<div style="float: left; text-align: left; padding:1em"> ❑ Check whether dissection involves ascending aorta</div> |J02=Yes}}
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| {{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
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| {{familytree | | | | |!| | | | | | | K01 | | | | | | |!| | | | | |K01=No}}
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| {{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}}
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| {{familytree | | | | |`|-|-| L01 |-|-|'| | | | | | | |!| | | | | |L01=<div style="float: left; text-align: left; padding:1em">❑ Control blood pressure
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| : ❑ Intravenous vasodilator</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | M01 | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | N01 |-| N02 |-| N03 |-|-|'| | | | | |}}
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| {{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | O01 | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | P01 | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| ==FIRE==
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| {{familytree/start}} | | {{familytree/start}} |
| {{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01=Suspected aortic dissection }} | | {{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01=Suspected aortic dissection }} |
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| :❑ Pericardial effusion <br> | | :❑ Pericardial effusion <br> |
| :❑ Regional wall motion abnormality (RWMA) <br> | | :❑ Regional wall motion abnormality (RWMA) <br> |
| :❑ Dilated root <br> | | :❑ Dilated aortic root <br> |
| :❑ Aortic regurgitation (AR)}} </div> |D02=Continue with diagnostic approach }} | | :❑ Aortic regurgitation (AR)}} </div> |D02=Continue with diagnostic approach }} |
| {{familytree | | | | | | |!| | | | | | | | | | | | | | | | }} | | {{familytree | | | | | | |!| | | | | | | | | | | | | | | | }} |
| | | | | | | | | Suspected aortic dissection | | | | | | | | | | |
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| | | | | | | | | ❑ Look for the following cardinal signs & symptoms:
- ❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing)
- ❑ Asymmetric blood pressure in extremities
- ❑ Shock
- ❑ Pulse deficit
- ❑ Evolving aortic regurgitation murmur
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| | | | | Unstable patient | | | | | | Stable patient | | | | | | |
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| | | | | ❑ Order urgent TTE
❑ Look for the following high risk features:
- ❑ Pericardial effusion
- ❑ Regional wall motion abnormality (RWMA)
- ❑ Dilated aortic root
- ❑ Aortic regurgitation (AR)
| | | | | | Continue with diagnostic approach | | | | | | |
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| | | | | ❑ Aortic dissection confirmed
❑ Transfer to Cardio-thoracic unit
❑ Perform TEE in CCU or cardiac OR | | | | | | | | | | | | | | |
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| | | | | ❑ Proceed to surgery | | | | | | | | | | | | | | |
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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