Diferencia entre revisiones de «Nontraumatic thoracic aortic dissection»
Sin resumen de edición |
Sin resumen de edición |
||
| Línea 1: | Línea 1: | ||
== Background == | == Background == | ||
==Risk Factors== | |||
*HTN | |||
*Smoking | |||
*Cocaine | |||
*3rd trimester pregnancy | |||
*Decelerating trauma | |||
*Marfans | |||
=== Classification === | === Classification === | ||
Stanford: | Stanford: | ||
*Type A - involves ascending Aorta, +/- descending Ao | |||
*Type A - involves ascending Aorta, +/- descending Ao | *Type B - distal to the origin of the L subclavian a | ||
*Type B - distal to the origin of the L subclavian a | |||
== Diagnosis == | == Diagnosis == | ||
=== History === | === History === | ||
*Pain - Abrupt, severe (90% of pts) | |||
*Pain - 90% | *Vasovagal - sweat, N\V, lt headed | ||
* | |||
*Neurologic Deficit - 20-40% | *Neurologic Deficit - 20-40% | ||
* | *Syncope - 5-10% | ||
=== Physical Exam === | === Physical Exam === | ||
*Tachycardia | *Tachycardia | ||
*Pulse | *Pulse discrepencies - (50% of proximal lesions but can be fleeting) | ||
*Aortic | *Aortic regurgitation | ||
*Tamponade | *Tamponade | ||
*Neuro - hemiplegia, parapesia, neuropathy | *Neuro - hemiplegia, parapesia, neuropathy | ||
| Línea 41: | Línea 30: | ||
=== Studies === | === Studies === | ||
*D-Dimer always elevated (sensitive but not specific) | *D-Dimer always elevated (sensitive but not specific) | ||
*ECG - Vent. hypertrophy from HTN, 10-40% may show ischemia or infarction, 33% normal | *ECG - Vent. hypertrophy from HTN, 10-40% may show ischemia or infarction, 33% normal | ||
| Línea 50: | Línea 38: | ||
== Treatment == | == Treatment == | ||
Keep BP 100-120sys, HR 60-80 | Keep BP 100-120sys, HR 60-80 | ||
| Línea 85: | Línea 72: | ||
Adapted from Donaldson, Bessen, Pani, DeBonis | Adapted from Donaldson, Bessen, Pani, DeBonis | ||
[[Category:Cards]] | |||
Revisión del 21:51 22 may 2011
Background
Risk Factors
- HTN
- Smoking
- Cocaine
- 3rd trimester pregnancy
- Decelerating trauma
- Marfans
Classification
Stanford:
- Type A - involves ascending Aorta, +/- descending Ao
- Type B - distal to the origin of the L subclavian a
Diagnosis
History
- Pain - Abrupt, severe (90% of pts)
- Vasovagal - sweat, N\V, lt headed
- Neurologic Deficit - 20-40%
- Syncope - 5-10%
Physical Exam
- Tachycardia
- Pulse discrepencies - (50% of proximal lesions but can be fleeting)
- Aortic regurgitation
- Tamponade
- Neuro - hemiplegia, parapesia, neuropathy
- Rare - fever unknown origin
Studies
- D-Dimer always elevated (sensitive but not specific)
- ECG - Vent. hypertrophy from HTN, 10-40% may show ischemia or infarction, 33% normal
- CXR - 60-90% mediastinal widening (S/S 67/70), double shadow, aortic knob, CA+ sign rare but specific, pleural effusions
- Echo (TEE) (S/S 97-100/90-100)
- CT & MRI - 95%
- Aortography (S/S 94/88)
Treatment
Keep BP 100-120sys, HR 60-80
- Nitroprusside (0.5-1.0mcg/kg/min; titrate) & B-blocker eg esmolol (0.5mg/kg loading, 0.05mg/kg/min infusion; titrate)
- Labetalol (10-20mg IV q10mins, or initial infusion rate at 2mg/min; titrate) or
- Verapamil
1. Type A - Surgery, unless worsening stroke
2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture.
Complications
- Rupture
- pericardium --> tamponade
- mediastinum --> hemothorax
- Obstruction of branch vessels
- coronaries --> acute MI
- arch vessels --> stroke
- lumbar --> paraplegia
- mesenteric, renal, or limb ischemia
- AV Insufficiency
- diastolic murmur and CHF
Prognosis
Uncomplicated Type B with aggressive medical therapy
- 30 day mortality: 10%
- 5 year mortality: 45-60%
Source
Adapted from Donaldson, Bessen, Pani, DeBonis