Diferencia entre revisiones de «Nontraumatic thoracic aortic dissection»
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== Background ==
== Background ==
==Risk Factors==
==Risk Factors==
*HTN
*HTN
Línea 9: Línea 8:
*Marfans
*Marfans


=== Classification ===
===Classification (Stanford)===
Stanford:
*Type A - Involves ascending Aorta, +/- descending Ao
*Type A - involves ascending Aorta, +/- descending Ao
**Requires surgery
*Type B - distal to the origin of the L subclavian a
*Type B - Starts distal to origin of L subclavian
**Surgery versus endovascular versus medical


== Diagnosis ==
==Diagnosis==
=== History ===
===History===
*Pain - Abrupt, severe (90% of pts)
*Chest Pain - Abrupt, severe (90% of pts)
*Vasovagal - sweat, N\V, lt headed
*Neurologic Deficit
*Neurologic Deficit - 20-40%
*Syncope (10%)
*Syncope - 5-10%


=== Physical Exam ===
===Physical Exam===
*Tachycardia
*Pulse discrepencies (15%)
*Pulse discrepencies (30% of pts) of proximal lesions but can be fleeting)
*Aortic regurgitation (30%)
*Aortic regurgitation (30% of pts)
*Tamponade
*Tamponade
*Neuro - hemiplegia, parapesia, neuropathy (15%)
*Neuro - hemiplegia, parapesia, neuropathy (15%)
*Rare - fever unknown origin


=== Studies ===
===Studies===
*D-Dimer always elevated (sensitive but not specific)
*D-Dimer always elevated
*ECG - Vent. hypertrophy from HTN, 10-40% may show ischemia or infarction, 33% normal
*ECG
**Ischemia - 15%
**Nonspec ST-T changes - 40%
*CXR  
*CXR  
**Abnormal in 90%
**Abnormal in 90%
***Mediastinal widening, double shadow, aortic knob, CA+ sign, pleural effusion
***Mediastinal widening
*Echo (TEE) (S/S 97-100/90-100)
***Aaortic knob
*CT & MRI - 95%
***Pleural effusion
*Aortography (S/S 94/88)
*CT
**Study of choice


== Treatment ==
== Treatment ==
Keep BP 100-120sys, HR 60-80
*Keep BP 100-120sys, HR 60-80
 
#Beta-Blockers
#Nitroprusside (0.5-1.0mcg/kg/min; titrate) & B-blocker eg esmolol (0.5mg/kg loading, 0.05mg/kg/min infusion; titrate)
##Esmolol
#Labetalol (10-20mg IV q10mins, or initial infusion rate at 2mg/min; titrate) or
###Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
#Verapamil
##Metoprolol
 
###5mg IV x 3; infuse at 2-5mg/hr
1. Type A - Surgery, unless worsening stroke
##Labetalol
 
###10-20mg w/ repeat doses of 20-40mg q10min up to 300mg
2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture.
#Vasodilators
 
##Only use if beta-blocker is ineffective
== Complications ==
##Do not use without a beta-blocker
##Nitroprusside 0.3-0.5mcg/kg/min


==Complications==
*AV RegurgitationInsufficiency
**CHF w/ diastolic murmur
*Rupture
*Rupture
**pericardium --> tamponade
**Pericardium > tamponade
**mediastinum --> hemothorax
**Mediastinum > hemothorax
*Obstruction of branch vessels
*Vascular obstruction
**coronaries --> acute MI
**Coronary > ACS
**arch vessels --> stroke
**Carotid > CVA
**lumbar --> paraplegia
**Lumbar > Paraplegia
**mesenteric, renal, or limb ischemia
**Mesenteric, renal, limb
*AV Insufficiency
**diastolic murmur and CHF
 
== Prognosis ==
 
Uncomplicated Type B with aggressive medical therapy


*30 day mortality: 10%
*5 year mortality: 45-60%


== Source ==
== Source ==
Tintinalli


Adapted from Donaldson, Bessen, Pani, DeBonis


[[Category:Cards]]
[[Category:Cards]]

Revisión del 23:16 22 may 2011

Background

Risk Factors

  • HTN
  • Smoking
  • Cocaine
  • 3rd trimester pregnancy
  • Decelerating trauma
  • Marfans

Classification (Stanford)

  • Type A - Involves ascending Aorta, +/- descending Ao
    • Requires surgery
  • Type B - Starts distal to origin of L subclavian
    • Surgery versus endovascular versus medical

Diagnosis

History

  • Chest Pain - Abrupt, severe (90% of pts)
  • Neurologic Deficit
  • Syncope (10%)

Physical Exam

  • Pulse discrepencies (15%)
  • Aortic regurgitation (30%)
  • Tamponade
  • Neuro - hemiplegia, parapesia, neuropathy (15%)

Studies

  • D-Dimer always elevated
  • ECG
    • Ischemia - 15%
    • Nonspec ST-T changes - 40%
  • CXR
    • Abnormal in 90%
      • Mediastinal widening
      • Aaortic knob
      • Pleural effusion
  • CT
    • Study of choice

Treatment

  • Keep BP 100-120sys, HR 60-80
  1. Beta-Blockers
    1. Esmolol
      1. Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
    2. Metoprolol
      1. 5mg IV x 3; infuse at 2-5mg/hr
    3. Labetalol
      1. 10-20mg w/ repeat doses of 20-40mg q10min up to 300mg
  2. Vasodilators
    1. Only use if beta-blocker is ineffective
    2. Do not use without a beta-blocker
    3. Nitroprusside 0.3-0.5mcg/kg/min

Complications

  • AV RegurgitationInsufficiency
    • CHF w/ diastolic murmur
  • Rupture
    • Pericardium > tamponade
    • Mediastinum > hemothorax
  • Vascular obstruction
    • Coronary > ACS
    • Carotid > CVA
    • Lumbar > Paraplegia
    • Mesenteric, renal, limb


Source

Tintinalli

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