Aortic dissection resident survival guide: Difference between revisions
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:❑ '''Pulse deficit involving carotid, femoral or subclavian arteries<sup>*</sup>''' | :❑ '''Pulse deficit involving carotid, femoral or subclavian arteries<sup>*</sup>''' | ||
:❑ Increased sweating ([[anxiety]], feeling of impending doom) suggestive of [[myocardial infarction]] | :❑ Increased sweating ([[anxiety]], feeling of impending doom) suggestive of [[myocardial infarction]] | ||
❑ Head/neck examination: | ❑ Head/neck examination: | ||
:❑ ↑ JVP | :❑ ↑ JVP | ||
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{{ familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | }} | {{ familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | }} | ||
{{ familytree | | | | | | | | | | | | D01 | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em;">❑ Assess the severity by counting the high risk features below marked in '''bold''' and by * | {{ familytree | | | | | | | | | | | | D01 | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em;">❑ Assess the severity by counting the high risk features below marked in '''bold''' and by * | ||
:❑ '''Chest pain described as <br>tearing, ripping, sharp or stabbing<sup>*</sup>''' | :❑ Symptoms | ||
:❑ '''Sudden onset of pain and <br>increasing in intensity<sup>*</sup>''' | ::❑ '''Chest pain described as <br>tearing, ripping, sharp or stabbing<sup>*</sup>''' | ||
:❑ '''Aortic disorder<sup>*</sup>''' | ::❑ '''Sudden onset of pain and <br>increasing in intensity<sup>*</sup>''' | ||
:❑ '''Aortic valve disease<sup>*</sup>''' | :❑ Family history | ||
:❑ '''Recent aortic manipulation<sup>*</sup>''' | ::❑ '''Aortic disorder<sup>*</sup>''' | ||
:❑ '''Difference in the blood pressure in both extremities<sup>*</sup>''' | :❑ Anatomic deformities | ||
:❑ '''Signs of [[shock]] (hypoperfusion)<sup>*</sup>''' | ::❑ '''Aortic valve disease<sup>*</sup>''' | ||
:❑ '''Pulse deficit involving carotid, femoral or subclavian arteries<sup>*</sup>''' | :❑ Iatrogenic | ||
:❑ '''[[Diastolic murmur]] suggestive of [[aortic regurgitation]]<sup>*</sup>''' | ::❑ '''Recent aortic manipulation<sup>*</sup>''' | ||
:❑ '''Signs suggestive of [[stroke]]<sup>*</sup>'''</div>}} | :❑ General examination | ||
::❑ '''Difference in the blood pressure in both extremities<sup>*</sup>''' | |||
::❑ '''Signs of [[shock]] (hypoperfusion)<sup>*</sup>''' | |||
:❑ Cardiovascular examination | |||
::❑ '''Pulse deficit involving carotid, femoral or subclavian arteries<sup>*</sup>''' | |||
::❑ '''[[Diastolic murmur]] suggestive of [[aortic regurgitation]]<sup>*</sup>''' | |||
:❑ Neurological examination | |||
::❑ '''[[Altered mental status]]<sup>*</sup>''' | |||
::❑ '''Signs suggestive of [[stroke]]<sup>*</sup>'''</div>}} | |||
{{ familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | }} | {{ familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | }} | ||
{{ familytree | | | | | | | | | | | | E01 | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">''' Consider alternate diagnosis:''' | {{ familytree | | | | | | | | | | | | E01 | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">''' Consider alternate diagnosis:''' |
Revision as of 16:46, 2 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]
Aortic dissection resident survival guide Microchapters |
---|
Overview |
Classification |
Causes |
Diagnosis |
Treatment |
Do's |
Dont's |
Overview
Aortic dissection is 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 dissection is a medical emergency and can quickly lead to death, even with optimal treatment, as a result of decreased blood supply to other organs, cardiac failure, and sometimes rupture of the aorta. Diagnosis is made with imaging studies like Transesophageal echocardiography (TEE), Computed tomography (CT) or Magnetic resonance imaging (MRI). Treatment depends according to the anatomic location of the aorta involved. Surgery is usually required for dissections that involve the aortic arch, while dissections of the part further away from the heart may be treated with antihypertensive medications.
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 aortic dissection into two types based on involvement of involvement of the ascending aorta
- Type A: Ascending aortic dissection involving ascending aorta and/or aortic arch, and possibly the descending aorta. The tear can originate in the ascending aorta, the aortic arch, or, more rarely, in the descending aorta. It includes DeBakey types I and II, which generally require primary surgical treatment
- Type B: Aortic dissection involving descending aorta or the arch (distal to the left subclavian artery), without involvement of the ascending aorta. It includes DeBakey type III. It is generally treated medically as initial treatment with surgery is reserved for complication.
- DeBakey classification categorizes the dissection based on where the original intimal tear is located and the extent of the dissection (localized to either the ascending aorta or descending aorta, or involves both the ascending and descending aorta).
- Type I: Starts at ascending aorta and extends 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
- Classification according to the proximity
- Proximal: Ascending aortic involvement
- Distal: Descending aortic involvement distal to left subclavian artery
- Aortic dissection can be further classifies by the time of onset:
- Acute: Onset within 2 weeks of onset of pain
- Subacute: Onset within 2-6 weeks of onset of pain
- Chronic: Onset within 6 weeks of pain.
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]
First Initial Rapid Evaluation of Suspected Aortic Dissection
Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of Aortic dissection.
❑ Identify cardinal signs and symptoms that increase the pretest probability of acute aortic rupture ❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing) | |||||||||||||||||||||||||||||||||||||||||||||
Unstable patient | Stable patient | ||||||||||||||||||||||||||||||||||||||||||||
❑ Order urgent TTE ❑ Look for the following high risk features:
| Continue with diagnostic approach | ||||||||||||||||||||||||||||||||||||||||||||
❑ Aortic dissection confirmed
❑ Transfer to Cardio-thoracic unit | |||||||||||||||||||||||||||||||||||||||||||||
❑ Proceed to surgery | |||||||||||||||||||||||||||||||||||||||||||||
Diagnosis
Shown below is a diagnostic algorithm depicting the management of Aortic dissection according to the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
Characterize the symptoms: ❑ Cardiac
❑ Extra cardiac
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Obtain a detailed history: ❑ Family history
❑ Anatomic deformities
❑ Iatrogenic
❑ Lifestyle
❑ Trauma
❑ Inflammatory vasculitis ❑ Aortitis | |||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ General examination:
❑ Head/neck examination:
❑ Cardiovascular examination:
❑ Respiratory examination
❑ Abdominal examination:
❑ Neurological examination:
❑ Extremity examination: ❑ Ophthalmological examination | |||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess the severity by counting the high risk features below marked in bold and by *
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternate diagnosis:
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Low Risk ❑ No high risk features present ❑ Clinical presentation is not initially suggestive for dissection but aortic imaging may help in the absence of alternative diagnosis | Intermediate Risk ❑ Single high risk present ❑ Concerning presentation for acute dissection and requires aortic imaging if no alternate diagnosis can be reached | High Risk ❑ Two or more high risk features present ❑ Acute dissection requiring immediate surgical evaluation and expedited aortic imaging | |||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can alternate diagnosis be ruled out | ❑ Order an EKG
❑ Does EKG show ST elevation | ||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ❑ Consider immediate surgical consultation and do aortic imaging as soon as possible | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Treat accordingly | ❑ Initiate appropriate therapy
❑ Check whether it helped to alleviate the symptom
| ❑ Order a coronary angiography and Treat like a primary acute coronary syndrome (ACS) unless perfusion deficits are present then consider immediate coronary reperfusion therapy ❑ Can the lesion be identified by coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||
❑ Evaluate clinical scenario for risk factors for Thoracic Aortic Disease (TAD)
| Detailed and accelerated aortic imaging | ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Do a detailed aortic imaging for thoracic aortic disease | ❑ Do aortic imaging as soon as possible
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| ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can aortic dissection be confirmed by imaging study | |||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Start appropriate therapy | ❑ Obtain a secondary imaging study if there is high cinical suscpicion even if the initial aortic imaging studies are negative | ||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm depicting the medical management of Aortic dissection according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
Confirmed aortic dissection ❑ Check whether dissection occurred in ascending aorta | Yes | Consider surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Start Medical management | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check Vitals
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Control rate and pressure
❑ Goal Heart rate should be 60 beats per minute ❑ Pain control
| ❑ Type A dissection
❑ Expedited surgical consultation and consider surgery (Urgent)
❑ Rule out complications using imaging study | ❑ Type B dissection
❑ Intravenous fluid replacement
❑ Start vasopressor if still hypotensive ❑ Find out etiology of hypertension
❑ Consider surgical evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can the cause of hypotension respond to surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Monitor vitals closely
| No | Yes | Consider surgical management | ||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check whether dissection involves ascending aorta | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Control blood pressure
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Monitor vitals closely
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check for any complications which might require surgery
| Yes | ❑ Consider surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Switch to oral medications
❑ Follow up in the outpatient | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm depicting the surgical management of Aortic dissection according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
❑ Imaging study confirms aortic dissection ❑ Check whether dissection occurred in ascending aorta | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Assess suitability for surgery ❑ Patient stable for pre-op testing? | No | Medical management | |||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Age > 40? | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Assess need for pre-operative coronary angiography
| No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform angiography Is significant CAD detected on angiography? | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Plan for CABG at the time of aortic dissection repair | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform urgent operative management | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform intra-operative assessment of aortic valve by Transesophageal echocardiography (TEE) for presence of one of the following:
| |||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||
❑ Perform graft replacement of ascending aorta ± aortic arch | ❑ Perform graft replacement of ascending aorta ± aortic arch ❑ Consider repair/replacement of aortic valve | ||||||||||||||||||||||||||||||||||||||||||||
Do's
History and Examination
- For pre-test risk determination include information about:
- Medical History
- Family history and ask specifically for family history of aortic dissection or thoracic aneurysm
- Pain history
- Do a detailed physical examination to identify findings for certain high risk conditions like: (class I, level of evidence B)
- Marfan's syndrome
- Loeys-Dietz syndrome
- Ehlers-Danlos syndrome
- Turner's syndrome
- Connective tissue disorder
- Check for genetic mutations predisposing to dissection: (class I, level of evidence B)
- Any recent aortic or surgical or catheter manipulation. (class I, level of evidence C)
- Ask in detail about the pain. Include the following: (class I, level of evidence B)
- Onset of pain whether abrupt or instantaneous
- Severity of pain
- Quality of pain whether ripping, tearing,stabbing or sharp.
- Check for the following features on examination: (class I, level of evidence B)
- Pulse deficits
- Blood pressure (systolic) difference of above 20 mm of hg in limbs
- New aortic regurgitation features
- Focal neurological deficit
- Patients less than 40 years of age and presenting with sudden chest, abdominal or back pain should be evaluated for high risk conditions.
- Patients presenting with features of syncope along with features of dissection should have a detailed neurological examination and cardiovascular examination to rule out pericardial tamponade and other neurological deficits. (class I, level of evidence C)
Screening Tests
- Do an EKG on all patients with dissection symptoms. (class I, level of evidence B)
- Treat the patient as an acute cardiac event, if ST elevation is present in EKG then, unless the patient has high risk factors for acute dissection.
- Perform coronary angiography followed by thrombolysis or percutaneous coronary intervention, if EKG shows ST elevation with no dissection features.
- Do order a X-ray for all patients with intermediate risk and a low risk to rule out alternate diagnosis. (class I, level of evidence C)
- High risk patients should be evaluated by transesophageal echocardiogram, computed tomography or magnetic resonance imaging to rule out dissection. (class I, level of evidence B)
- If the initial aortic imaging studies are negative, obtain a secondary imaging study if there is a high clinical suspicion. class III, level of evidence C
Initial Management
- Medical management should be aimed at decreasing aortic wall stress. (class I, level of evidence C)
- Titrate Beta blocker to maintain heart rate of 60 beats/ minute. (class I, level of evidence C)
- If beta blockers are contra indicated then use nondihyropyridine calcium channel blockers to control rate. (class I, level of evidence C)
- If BP remains above 120 mm of hg even after medical treatment then use angiotensin converting enzyme and other vasodilators to maintain end organ perfusion. (class I, level of evidence C)
Definitive Management
- Do a definitive aortic imaging study as soon as Chest X-ray suggests widened mediastinum.
- Goal is to maintain heart rate less than 60 beats / minute and blood pressure between 100 and 120 mm hg.
- Use Sodium nitroprusside as the first line for the treatment of hypertension. Nicardipine, nitroglycerin and fenoldopam can also be used.
- Use Esmolol in asthma, congestive heart failure or chronic obstructive pulmonary disease.
- Use Labetalol to maintain heart rate and blood pressure, it prevents usage of another vasodilator.
- Do a pericardiocentes for pericardial bleeding and dissection related hemopericardium.
- Do a plasma smooth muscle myosin heavy chain protein, D-dimer and high sensitive C-reactive protein to rule out alternate diagnosis.
- Do a surgical consultation for all patients once diagnosed with aortic dissection. This applies to patients presenting with dissection at any location. (class I, level of evidence C)
- Do an emergent repair in acute dissection of ascending aorta to prevent complications like rupture. (class I, level of evidence C)
- Consider surgical repair for all type A dissections as they involve the aortic valve. Ascending aortic dissections often involve the aortic valve, which, having lost its suspensory support, telescopes down into the aortic root, resulting in aortic incompetence. This needs re-suspending to re-seat the valve and repair / prevent coronary artery injury. The area of dissection is removed and replaced with a Dacron graft to prevent further dissection from occurring.
- Consider medical management for type B dissections, unless there is leaking, rupture or compromise to other organs, e.g. kidneys and life threatening conditions like perfusion deficit, dissection enlargement, aneurysmal enlargement or blood pressure refractory to treatment. (class I, level of evidence C)
Dont's
- Don't delay aortic imaging even if chest x-ray is negative(class III, level of evidence C).
- Don't use beta blocker in patients having aortic regurgitation as they may block the tachycardia caused by compensation.
- Don't use vasodilator before heart rate is controlled otherwise there would be reflex tachycardia which would increase the stress on aorta and worsening the dissection.
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.
- ↑ 6.0 6.1 6.2 "http://circ.ahajournals.org/content/121/13/e266.full". External link in
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(help)