Diferencia entre revisiones de «Nontraumatic thoracic aortic dissection»
Sin resumen de edición |
Sin resumen de edición |
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==Background== | == Background == | ||
2-3x > men usually 50-70 yrs old | 2-3x > men usually 50-70 yrs old | ||
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Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell) | Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell) | ||
RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia | RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia | ||
===Classification=== | === Classification === | ||
Stanford: | Stanford: | ||
Type A - involves ascending Aorta, +/- descending Ao (DeBakey I & II) | *Type A - involves ascending Aorta, +/- descending Ao (DeBakey I & II) | ||
*Type B - distal to the origin of the L subclavian a (DeBakey III) | |||
<br/>DeBakey: | |||
DeBakey: | |||
*Type I - ascending and descending Ao | |||
*Type II - isolated to ascending Ao | |||
*Type III - isolated to descending Ao | |||
Chronic > 2wks otherwise Acute | Chronic > 2wks otherwise Acute | ||
== Diagnosis == | |||
=== History === | |||
===History=== | |||
*Pain - 90% - abrupt | |||
*VasoVagal - sweat, N\V, lt headed | |||
*Neurologic Deficit - 20-40% | |||
*Syncopy - 5-10% | |||
=== Physical Exam === | |||
*Tachycardia | |||
*Pulse Deficits/Discrepencies - (50% of proximal lesions but can be fleeting) | |||
*Aortic Insufficiency | |||
*Tamponade | |||
*Neuro - hemiplegia, parapesia, neuropathy | |||
*Rare - fever unknown origin | *Rare - fever unknown origin | ||
=== 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 | |||
*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 == | |||
==Treatment== | |||
Keep BP 100-120sys, HR 60-80 | 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 | 1. Type A - Surgery, unless worsening stroke | ||
| Línea 87: | Línea 61: | ||
2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture. | 2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture. | ||
==Complications== | == Complications == | ||
* | *Rupture | ||
**pericardium --> tamponade | **pericardium --> tamponade | ||
**mediastinum --> hemothorax | **mediastinum --> hemothorax | ||
* | *Obstruction of branch vessels | ||
**coronaries --> acute MI | **coronaries --> acute MI | ||
**arch vessels --> stroke | **arch vessels --> stroke | ||
**lumbar --> paraplegia | **lumbar --> paraplegia | ||
**mesenteric, renal, or limb ischemia | **mesenteric, renal, or limb ischemia | ||
* | *AV Insufficiency | ||
*diastolic murmur and CHF | **diastolic murmur and CHF | ||
==Prognosis== | == Prognosis == | ||
Uncomplicated Type B with aggressive medical therapy | Uncomplicated Type B with aggressive medical therapy | ||
*30 day mortality: 10% | |||
*5 year mortality: 45-60% | |||
==Source== | == Source == | ||
Adapted from Donaldson, Bessen, Pani, DeBonis | Adapted from Donaldson, Bessen, Pani, DeBonis | ||
[[Category:Cards]] | <br/>[[Category:Cards]] | ||
Revisión del 16:18 9 mar 2011
Background
2-3x > men usually 50-70 yrs old
Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell)
RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia
Classification
Stanford:
- Type A - involves ascending Aorta, +/- descending Ao (DeBakey I & II)
- Type B - distal to the origin of the L subclavian a (DeBakey III)
DeBakey:
- Type I - ascending and descending Ao
- Type II - isolated to ascending Ao
- Type III - isolated to descending Ao
Chronic > 2wks otherwise Acute
Diagnosis
History
- Pain - 90% - abrupt
- VasoVagal - sweat, N\V, lt headed
- Neurologic Deficit - 20-40%
- Syncopy - 5-10%
Physical Exam
- Tachycardia
- Pulse Deficits/Discrepencies - (50% of proximal lesions but can be fleeting)
- Aortic Insufficiency
- 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