Case report

1
Case report

• 90-12-11 616 pm
• ??? ?? 64
• ?????,?????
• ?? LMD??, bradycardia
• vital signs BT 36.4, PR 50, RR 20, BP 120/60
• Triage class 1

2

• LMD Transfer note
• A middle aged male patient suffered from chest
  distress with SOB, and he was sent to our H. At
  ER complete ECG revealed mild ST-T elevation in
  II and aVF, and bradycardia was also noted and he
  received NTG 1 sl st and nasal O2 therapy, but
  s/s persisted
• R/O inf. MI Thanks for your attention

3

• Chief Complaint OPD ?, R/O AMI
• Present Illness
• Chest pain onset at 500 pm
• No radiate to back
• Radiate to neck
• Past personal and medical history
• ??????
• Smoking drinking
• HTN(-)

4
PE

• vital signs BT 36.4, PR 50, RR 20, BP 120/60
• Consciousness clear
• HEENT and neck No JVD
• Chest regular heart beat, bradycardia
• Abdomen Soft
• Pelvix Stable
• Ext symmetric 4 limbs pulse
• NE normal
• Impression???

5
Impression

• R/O AMI

6
Order sheet

• CBC/DC/PLT
• PT,aPTT
• ??
• N/S KVO
• NTG spray sl 2
• Morphine 3 mg iv st
• millisrol 3 cc/hr
• on monitor

7
Order sheet

• Troponin T
• portable CXR
• Rt side ECG
• ECG

8
ECG bradycardia
9
710 pm order

• Impression bradycardia, r/o hyperkalemia
• Calcium gluconate 1 amp iv st

10
750 pm Lab Data

• Glu110, BUN15, Cr1.1, Na146, K4.1
• CPK 107, CKMB 13
• Troponin Ilt 0.5

11
750 pm progress note

• S still chest pain
• O nausea(), Vomiting() 2 times
• pain will increase by inspiration or swallowing
• radiate to neck
• Not chest tightness
• Lab data K4.1 Tro.Ilt0.5 CKMB13 CK107
• A chest pain and bradycardia, cause ?
• P
• f/u cardiac enzyme
• check 4 limbs BP

12
Order sheet 810 pm

• F/U Troponin I, CPK, CKMB at 830 pm
• check 4 limbs BP st
• F/U ECG at 830 pm

13
845 ECG
14
840 pm

• 4 limbs BP
• RU 89/72 mmHg, LU 117/68 mmHg
• RL 151/81 mmHg, LL 141/78 mmHg

15
900 pm Progress note

• Rt upper limb cold, weak pulse
• Still chest pain
• CXR boulderline widening mediastinum
• R/O aortic disection
• arrange chest CT

16
919 pm Lab Data

• CPK 100
• CKMB 10
• Troponin I lt 0.5

17
920 pm progress note

• S chest severe pain
• O consciousness slear
• BP 100/60, PR 50 RR 16/min
• Neck supple
• Heart RHB with murmur
• lung clear
• Abdomen soft.normal active bowel sounds

18
920 pm progress note

• Ext
• muscle power 4 symmetric,
• Pulse RU limb , LU limb , RL and LL limb
• Aortic CT definite dissection in ascending aorta
• P
• control BP and PR
• consult CVS

19
1030 pm CVS note

• Aortic dissection, type A
• surgical repair is indicated
• admit to SICU for BP control and preop preparation

20
Aortic Dissection

• Manifestation
• Pain gt 90
• vasovagal symptoms
• Syncope 5
• neurologic deficit 20

21
Pain

• the most common complaint (gt 90 of cases)
• In almost all cases in which pain is not present,
  the patient either is unconscious or has a
  neurologic deficit that impairs pain perception.
• tearing, ripping, and knifelike, but
  may be characterized by different patients in
  many different ways.
• Typically the pain occurs abruptly and is most
  severe at onset.

22

• The location of the pain
• Anterior chest pain -- dissection of the
  ascending aorta
• neck and jaw -- dissection of the aortic arch,
• in the interscapular area --descending thoracic
  aorta
• in the lumbar area or abdomen-- involvement below
  the diaphragm
• migration -- propagation of the dissection
• has very high diagnostic accuracy for aortic
  dissection.
• In one study, 71 of patients with aortic
  dissection had migration of pain.

23

• Aortic dissection accompanied by vasovagal
  symptoms
• diaphoresis, nausea, vomiting, light-headedness,
  and severe apprehension.
• Syncope
• early course of aortic dissection, about 5 of
  cases.
• most associated with ascending aorta dissection
• dissection into the pericardium?pericardial
  tamponade
• Other causes of syncope secondary to aortic
  dissection are hypovolemia, excessive vagal tone,
  and cardiac conduction abnormalities.

24

• In approximately 20 of patients, neurologic
  deficit is the presenting manifestation of aortic
  dissection.
• The neurologic presentations are CVA, spinal cord
  ischemia, and peripheral nerve ischemia

25
Physical Examination.

• Appearance very apprehensive
• Tachycardia and signs of inadequate end-organ
  perfusion may be present even in the face of an
  elevated blood pressure.
• e.g., clammy skin, altered mental status, delayed
  capillary refill
• chronic hypertension gt 75 of patients
• may be exacerbated by a catecholamine release
  related to the acute event

26

• Severe hypertension refractory to medical therapy
  
• may occur if the dissection involvesthe renal
  arteries with subsequent renin release
• hypotension
• dissection has progressed back into the
  pericardium with resulting pericardial tamponade
• hypovolemia occurred from rupture along the aorta
• pseudohypotension
• the blood pressure in the arms is low or
  unobtainable and the central arterial pressure is
  normal orhigh.
• results from the interruption of blood flow to
  the subclavian arteries

27
Pulse deficits and discrepancies in blood
pressure between limbs

• Pulse deficits(a unilaterally weakened or absent
  pulse) in almost 50 of patients with proximal
  dissections
• Usually in the upper extremities
• mechanisms
• An intimal flap cover the true lumen of a branch
  vessel
• dissecting hematoma compress an adjacent true
  lumen.
• Careful documentation of pulses and frequent
  reexamination are important because pulse
  deficits are commonly transient

28
Acute aortic regurgitation

• This is identified clinically by
• Hypotension
• fulminant pulmonary edema
• aortic diastolic murmur (musical, vibrating
  quality with variable intensity)
• widened mediastinum on CXR
• Aortic regurgitation in 50 of type A
  dissections
• Rapid surgical correction affords the only chance
  for survival

29

• Hemorrhage into the pericardium or tamponade
  ???????
• Pericardial friction rub
• Jugular venous distension
• Pulsus paradoxus
• Muffled heart sounds
• Tachycardia
• Hypotension

30
Neurologic findings

• most common altered sensorium
• The most common focal neurologic abnormalities
• Hemiplegia
• Hemianesthesia
• Gaze preference to the affected side
• Ischemic paraparesis
• occurs in approximately 4 of dissections
• result of interruption of blood flow in the
  intercostal, lumbar, and anterior spinal
  arteries.
• Ischemic peripheral neuropathy
• may follow obstruction of the vessels that supply
  the upper and lower extremities

31
Uncommon clinical manifestations

• Hemoptysis
• a rare finding in aortic dissection and usually
  is caused by rupture of the aorta into lung
  tissue or by dissection of bronchial arteries
• Hoarseness
• from vocal cord paralysis may be caused by
  compression of the recurrent laryngeal nerve by
  the expanding dissecting hematoma
• Horners syndrome
• may result from compression of the superior
  cervical sympathetic ganglion by the dissected
  aorta.
• Superior vena cava syndrome

32

• Hematemesis
• Rupture of the aorta into the esophagus
• Bronchospasm
• Bronchial or tracheal compression
• Mesenteric infarction and myocardial infarction
  (MI) unusual
• Rarely, aortic dissection may present as a fever
  of unknown origin

33
Ancillary Evaluation

• Routine Laboratory Tests.
• of little value.
• Serial analysis of cardiac enzymes is usually
  negative.
• Microscopic hematuria may occur where the renal
  artery is involved

34
ECG

• EKG
• Commonly shows LVH reflecting long-standing
  hypertension
• Useful in excluding MI however, 10 to 40 of
  patients with aortic dissection may have EKG
  abnormalities suggesting ischemia or infarction
• Acute MI
• Proximal dissection that involves a coronary
  artery
• Heart block
• retrograde dissection into the interatrial septum
  with compression of the AV node

35
Chest X-Ray

• Routine chest x-ray studies will be abnormal in
  80 to 90 of cases.
• mediastinal widening gt75 of cases.
• The calcium sign uncommon but highly specific
• the calcium deposit separated from the outermost
  portion of the aorta gt 5 mm
• Double-density appearance of the aorta
• suggesting true and false channels

36

• localized bulge along a normally smooth aortic
  contour
• disparity in the caliber between the descending
  and ascending aorta
• Displacement of the trachea or nasogastric tube
  to the right by the dissection
• Previous CXR very useful for comparison
• Pleural effusions are common and usually occur on
  the left side
• small effusion periaortic inflammation
• a large effusion leaking or rupture of the
  dissection into the pleural space? Thoracentesis

37
Echocardiography

• Until recently, echocardiography has not been a
  useful tool in the detection and delineation of
  aortic dissection
• M-mode and 2-D ultrasound through a transthoracic
  approach have a sensitivity and specificity that
  is unacceptably low, ranging from 77 to 80 and
  93 to 96, respectively, giving a predictive
  value that results in too many false-negative
  tests
• The transthoracic approach is hindered by
  overlying sternum, ribs, and lungs

38
Transesophageal Echocardiography

• Dramatically improved the quality of
  echocardiography in the diagnosis of aortic
  dissection
• This modality has been shown to be 97 to 100
  sensitive and 90 to 100 specific
• There can be some difficulty in evaluating the
  ascending aorta and proximal arch because of the
  interposition of the air-filled trachea and left
  main bronchus, but this problem has been largely
  overcome by the use of the newer biplane probes.

39
TEE

• Multiplane (or omniplane) probes may be of still
  greater usefulness because they allow additional
  views of cardiovascular structures in oblique
  planes
• Transesophageal echocardiography (TEE) is quick
  and can be easily performed at the bedside in the
  ED.
• Few serious side effects or contraindications
• Requires no radiation or contrast injection.

40
TEE

• TEE is excellent at detecting pericardial
  effusion and compares favorably with other
  modalities in evaluating aortic regurgitation,
  flow in the proximal coronary arteries, the
  intimal flap, and site of entry.
• For these reasons, TEE has become the primary
  diagnostic method for detecting aortic dissection
  in many institutions

41
CT

• The rates of both false-positive and
  false-negative diagnoses of aortic dissection
  appear to be less than 5.
• Signs on the CT scan that are particularly
  suggestive of aortic dissection include
  dilatation of the aorta, identification of an
  intimal flap, differential rates of flow in true
  and false channels, and the clear demonstration
  of both the false and true lumina.

42
Limitations of the CT scan

• It does not provide information about the
  presence of aortic regurgitation, which is
  important in determining appropriate therapy
• Fails to provide reliable information about the
  relationship of the dissection to the major
  arterial branches of the aorta
• Some patients have serious adverse reactions to
  the administration of IV contrast material
• A CT scan is time consuming and requires the
  patient to be outside of the ED or intensive care
  unit

43
Aortography

• In most institutions, aortography remains the
  standard imaging modality for detection of aortic
  dissection against which all other modalities are
  measured
• In skilled hands, this procedure can be performed
  with low morbidity and mortality and with high
  diagnostic accuracy

44
Aortography

• Filling of a false channel
• Channels with or without an intervening intimal
  flap
• Distortion of the true lumen by either a patent
  or thrombosed false lumen
• Thickening of the aortic wall by more than 5 to 6
  mm caused by a thrombosed false lumen
• Displaced intimal calcification

45
Aortography

• Misdiagnoses occur in one of several situations
• Thrombosis of the false channel may prevent
  visualization of either the intimal flap or a
  double lumen.
• The true and false lumina may opacify
  simultaneously and, therefore, may not be clearly
  delineated from one another.
• The intimal flap may not be visualized when it is
  located in a plane tangential to the x-ray beam

46
The disadvantages of aortography

• invasive techniques, requires that a catheter be
  inserted into a potentially abnormal aorta.
• It is also the most expensive of the modalities
  available.
• Specialized personnel are required, and the
  patient must be removed from the ED.
• Other disadvantages are the risks of IV contrast
  material and inadequate detection of pleural leak

47
Aortography

• Despite these limitations, aortography remains an
  informative procedure to diagnose aortic
  dissection.
• It is a sensitive test for detecting aortic
  dissection and very accurate for determining the
  site of the intimal tear and the extent of the
  dissection
• Aortic regurgitation is easily demonstrated with
  aortography, and it is the only procedure that
  demonstrates the extent and location of
  dissection into aortic side branches

48
CT versus Aortography

• The CT scan has greater contrast resolution and
  detects small or delayed differences in the
  opacification of true and false channels.
• A CT scan may be able to detect a thrombosed
  false lumen despite nonopacification, whereas
  aortography cannot.
• The axial scanning plane in a CT scan is
  perpendicular to the intimal flap so that the
  detection of the intimal flap is easier.
• Does not require arterial catheterization, and
  may reveal other abnormalities that explain the
  patients clinical presentation

49
MRI

• For the evaluation of the stable patient with
  suspected aortic dissection
• Useful in
• the evaluation of chronic aortic dissection,
• in the follow-up of postoperative patients
• for monitoring nonoperative patients for
  progression of the dissection

50
TREATMENT
51
Treatment at Emergency Department

• All patients suspected of having an acute aortic
  dissection should receive careful monitoring of
  cardiac rhythm, blood pressure, and urine output
• The objectives of early management are to
  eliminate the forces favoring progression of the
  dissection by maintaining systolic blood pressure
  between 100 and 120 mm Hg (or the lowest level
  commensurate with vital organ perfusion) and by
  reducing the force of cardiac contraction and the
  rate of rise of the arterial pulse (dP/dT).

52

• Narcotics should be administered in adequate
  amounts for pain control
• Therapy should begin immediately to attain these
  goals while other diagnostic tests are performed
• The early hours are a critical period
• The mortality in the first 24 to 48 hours of
  aortic dissection is between 1 and 2 per hour.
• Those patients presenting with hypotension
  secondary to aortic rupture or pericardial
  tamponade should be resuscitated with IV fluids
  and blood transfusions
• More typically, the patient will be hypertensive

53
Sodium nitroprusside

• Prompt reduction of the blood pressure can be
  accomplished with sodium nitroprusside
• 50 to 100 mg are mixed in 500 ml of D5W and
  initially infused at a rate of 0.5 to 3 mg/kg/min
• The rate is adjusted to achieve the desired blood
  pressure
• The solution is light sensitive, and the bottle
  and tubing containing the mixture should be
  wrapped in aluminum foil

54
Sodium nitroprusside

• Because sodium nitroprusside increases the heart
  rate and may also increase the dP/dT,
  administration of this drug alone may worsen the
  dissection
• A b-adrenergic blocker must be used in
  conjunction with sodium nitroprusside to lower
  the dP/dT
• Propranolol
• more selective b-blocking agent such as
  metoprolol.
• Esmolol short-acting (continuous infusion)

55

• Trimethaphan camsylate
• effective in the initial treatment of acute
  aortic dissection
• It is generally used as a single agent and is the
  preferred drug in a patient who has a
  contraindication to b-blockers
• IV labetalol
• This drug has both a- and b-blockade properties
• May be used as a single agent for the management
  of aortic dissection

56
Definitive Therapy

• Type A acute aortic dissections require surgical
  treatment.
• The aortic segment containing the original
  intimal tear is resected when possible, with
  graft replacement of the ascending aorta to
  redirect blood into the true lumen.
• An operative mortality rate of 7 has recently
  been reported
• If aortic insufficiency is present, it can be
  corrected through aortic valve resuspension or
  replacement

57

• The only contraindication to immediate surgical
  repair of a type A dissection is the simultaneous
  occurrence of a progressing stroke.

58
Type B acute aortic dissections

• Definitive treatment is less clear
• Generally, these patients tend to be worse
  surgical risks
• The hospital mortality in patients treated
  without surgery who have acute type B dissections
  is 15 to 20, and that is comparable to or
  better than the mortality rate with surgery in
  most institutions, although the mortality rate in
  surgery for type B dissections appears to be
  decreasing

59
Uncomplicated distal dissections

• Patients who present with chronic aortic
  dissection have already survived their period of
  greatest mortality risk and are usually treated
  by blood pressure control unless complications
  mandate surgery
• Treated with blood pressure control
• Surgery has been reserved for those patients who
  have persistent pain, uncontrolled hypertension,
  occlusion of a major arterial trunk, frank aortic
  leaking or rupture, or development of a localized
  aneurysm

60

• However, as surgical management for these
  patients improves, medical therapy may be
  replaced by operative treatment as the preferred
  definitive approach
• All patients who have sustained and survived an
  aortic dissection, regardless of the type of
  definitive therapy used, require careful
  long-term management
• Major complications that may occur with time are
  redissection, the development of a localized
  aneurysm, and progressive aortic insufficiency

61

• Control of blood pressure is the cornerstone of
  therapy
• b-Blocking agents are the most commonly used oral
  antihypertensive drugs in the treatment of these
  patients
• other agents, such as thiazide diuretics, calcium
  channel blockers, and angiotensin-converting
  enzyme inhibitors, may need to be added.

62
Follow-up visits

• Blood pressure monitoring
• Detecting signs of recurrence or progression of
  disease
• Chest pain
• Signs of congestive heart failure
• Presence of aortic insufficiency
• Mediastinal size can be followed by chest x-ray
  studies.
• Periodically these patients should undergo either
  a CT scan or MRI scan to determine the status of
  the aorta