# Type *** Aortic Dissection
-- ABCs: Consult CT surgery urgently; consider Heme involvement if on AC and may need reversal
-- Chart Check: prior echos, surgeries, h/o HTN, CTD, bicuspid valve
-- HPI Intake: tearing chest/back pain
-- Can't Miss: Type A dissection; upper extremity BP differential >20
-- Admission Orders: continuous telemetry; CBC, BMP (renal fx), coags, troponin (ACS), D-dimer, type and screen, EKG, CXR, CTA, Echo
-- Initial Treatment to Consider: *** Type A dissection needs immediate BP reduction and sugical repair
-- History: *** known aneurysm, h/o smoking, HLD, HTN, CTD, bicuspid valve, prior surgery, autoimmune dx, syphilis, FHx dissection
-- Clinical/Exam: *** tearing chest and back pain, aortic regurg murmur, pulse deficit, upper extemity BP differential >20, e/o CHF
-- Data: *** CXR, CTA, creatinine
-- Etiology/DDx: *** Type A (ascending +/- descending), Type B (descending); Type 1 - ascending AND descending, Type 2 - ascending only, Type 3 - descending only
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u CBC, BMP (renal fx), coags, troponin (ACS), D-dimer, type and screen
-- f/u EKG, CXR, CTA, Echo
-- Continuous telemetry and pulse oximetry
-- Serial bilateral BP measurements - consider A-line
-- BP: *** goal to lower HR <60 and SBP to 100-120 with IV labetalol/esmolol first; IV nitroprusside or nicardipine if SBP remains >120; if hypotensive give fluids and norepi but avoid inotropes
-- Pain: *** IV morphine
-- Consider need for AC reversal
-- Urgent/Emergent open repair for Type A vs medical management with consideration of TEVAR for Type B
-- statin, beta-blocker, low dose ASA especially upon discharge
-- Guidance: smoking cessation, BP reduction, avoid straining
PDF coming soon!
An aortic dissection is a tear in the intima that results in a false lumen, often due to HTN. AAA and TAA are often due to atherosclerotic disease with smoking, male sex, and age >65yo also being major risk factors. Stanford Type A dissections include the ascending +/- descending and Type B involves just the descending aorta. Type A dissection is managed surgically whereas Type B is usually managed medically unless high risk or "complicated" in which case TEVAR is preferred to open surgery. In both, the goal is to reduce BP, but you should avoid vasodilators without concomitant BB as this can lead to reflex tachycardia which will increase wall stress.