Diferencia entre revisiones de «Nontraumatic thoracic aortic dissection»
| Línea 50: | Línea 50: | ||
#Beta-Blockers | #Beta-Blockers | ||
##Esmolol | ##Esmolol | ||
###Advantage of short half life, easily titratable | |||
###Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min | ###Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min | ||
##Metoprolol | ##Metoprolol | ||
| Línea 57: | Línea 58: | ||
#Vasodilators | #Vasodilators | ||
##Only use if beta-blocker is ineffective | ##Only use if beta-blocker is ineffective | ||
##Do not use without a beta-blocker | ##Do not use without a beta-blocker, in order to suppress reflex tachycardia | ||
##Nitroprusside 0.3-0.5mcg/kg/min | ##Nitroprusside 0.3-0.5mcg/kg/min | ||
Revisión del 00:29 28 oct 2011
Background
- Incidence estimated 2.6-3.5 per 100,000 person years
- most commonly seen in males, 60-80 yrs old
Risk Factors
- HTN
- Inflammatory vasculitis
- Smoking
- Cocaine
- 3rd trimester pregnancy
- Decelerating trauma
- Connective tissue disorders (Marfan, Ehlers Danlos syndrome)
- Bicuspid aortic valve
- History of surgery (coarctation of aorta repair, aortic valve replacement, cardiac cath)
Classification (Stanford)
- Type A - Involves any portion of ascending aorta
- Requires surgery
- Type B - Isolated to descending aorta
- Primarily medical management with surgery consultation
Diagnosis
History
- Chest Pain - Abrupt, severe (90% of pts), classically radiating to back
- Neurologic Deficit
- Syncope (10%)
Physical Exam
- Pulse discrepencies (15%)
- Aortic regurgitation (30%)
- Tamponade
- Neuro - hemiplegia, parapesia, neuropathy (15%)
Studies
- ECG
- Ischemia - 15%
- Nonspec ST-T changes - 40%
- CXR
- Abnormal in 90%
- Mediastinal widening (seen in 63%)
- Left sided pleural effusion (seen in 19%)
- Widening of aortic contour, displaced calcification (6mm), aortic kinking, double density sign
- Abnormal in 90%
- CT Aortogram
- Study of choice
- TEE
- 99% sensitivity, 77% specificity when done alone
- Can aid in surgical planning with type A dissections
Treatment
- Keep BP 100-120sys, HR 60-80
- Beta-Blockers
- Esmolol
- Advantage of short half life, easily titratable
- Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
- Metoprolol
- 5mg IV x 3; infuse at 2-5mg/hr
- Labetalol
- 10-20mg w/ repeat doses of 20-40mg q10min up to 300mg
- Esmolol
- Vasodilators
- Only use if beta-blocker is ineffective
- Do not use without a beta-blocker, in order to suppress reflex tachycardia
- 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