Aortic Dissection
Lower Dp/Dt and Blood Pressure
Control Pain with fentanyl
Control Heart Rate/Inotropy with esmolol
See the esmolol drip sheet (YOU MUST CHECK ALL NUMBERS WITH YOUR OWN PHARMACY)
Control Blood Pressure
With in order of preference: clevidipine, nicardipine, nitroprusside, nitroglycerin
What about if the patient can't get beta-blockers?
What about labetalol?
A-lines
Why is the Patient's Blood Pressure Low?
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Myocardial Infarction
Andy Neill thankfully addressed my erroneous assumption that MIs in Dissection would only be right coronary infarctions
Does an anterior STEMI rule out dissection? – Emergency Medicine Ireland
and check out this article as well (J Emerg Trauma Shock 2011;4:273-278)
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Site of Blood Pressure Measurement
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Rupture of the Aorta
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Aortic Insufficiency
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Pericardial Tamponade
Neurodeficits
Intubation
Do a high-icp/vascular intubation (More to come on this)
Update
- Nicardipine and Esmolol are compatible and can be given through the same IV
Amal Mattu's Law of 4's
History
- Abrupt onset of Thorax Pain
- Ripping or Tearing
- Migrating Pain
- History of Aortic Problems (like TAA)
Physical
- Hypotension
- Pulse Deficit
- Neuro Deficit
- New Murmur
Physical
Now on to the Podcast…
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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Hi Scott,
Great podcast as always, the dosing information for esmolol and nicardipine are great and need to be disseminated through the nursing world. I am quite looking forward to the ICP/vascular intubation series. In my personal experience with video guided intubations, I am not very impressed with the success rates. Mainly from the loss of depth perception, my opinion, as well as the fact EVERYONE moves eyes from the pateint to the video monitor. I feel as if DL is quicker and more efficient. I look forward to your podcast and views
L
Wow, I guess I need to do a video laryngoscopy show as well.
[…] Podcast: Play in new window | Download (22.1MB) | Embed […]
very intersting podcast. you gave us multiple choices of drugs that we can use, because we dont have much here in Egypt
Oops, totally forgot. If the patient has contra-indications to beta-blockers, substitute diltiazem for esmolol.
IV lignocaine
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725712/
https://secure.muhealth.org/~ed/students/articles/AnnEM_49_p0084.pdf
http://bestbets.org/bets/bet.php?id=146
???
Evidence is clear–there is no evidence. It would be a great trial for someone to do. Until then you listed 3 papers, all looking at the same evidence. 2 came to 1 conclusion; the other 1 another.
Scott, another very informative podcast. The scenerio you gave was a 30 year old male. Is this not a very unusual case age wise? I know males have more instances of AD than females, but 30 years old……….? Was this a genetic issue with the young man? Also can you let us know how he did post operatively? Thanks again.
I work in a 15-bed ED in a semi-rural community ED. The last 5 TAD’s I’ve taken care of have all been < 65 years old. The most recent was a 34 year old farmer that syncopized, and then crawled 100 yards to his house where he called EMS. He took out his aortic root to his right renal! At least he told me "Somebody stabbed me in the chest," as a hint!
Super-scary!
[…] as of Jan 2013 EMCrit has now done a nice podcast on Aortic Dissection which is compulsory […]
Hi Scott,
I listen to your podcast on Thursday on aortic dissection . It was great. I just Had similar case this AM in a 34 years male that came with chest pain/sob . D- dimer was elevated and CTA shows dissecting aortic. Pt had no obvious risk factor. My nurses was furious when I said to start esmolol while Pt 131/55 and heart rate 55. But heart rate increase to 83 later . Do you know want was etiology of your patient dissection ? Any comment ?
Thanks
Cherinor
have no idea; my patient had no risk factors. He was tall and thin, but not Marfanoid.
Shortly after listening to your podcast on the way to work, we’re heading out to transport a mid-40’s male to a tertiary center who was suffering an aortic dissection (non-Marfanoid as well, but with a similar aged sibling who had suffered and survived the issue years earlier). He presented to a community ED three hours earlier with searing back pain and right lower extremity tingling. He had received just under a liter of crystalloid and a couple doses of morphine prior to our arrival (his blood pressure and heart rate were slightly above our threshold for control, so Fentanyl, Esmolol, and Nicardipine were instituted with good effect during a fortunately unremarkable transport). His mental status was an interesting aspect of this case. Initially, his strange behavior was attributed to the morphine doses, but he answered all orientation questions appropriately. He was occasionally asking to sleep, but mostly restless and perseverating like a patient who had suffered a head injury. We had a few thoughts on this (CVA, cerebral hypoperfusion), but I was wondering your take. (After we transferred care, we were fortunate enough to look over a few surgeon’s shoulders and look at the CT which showed a Stanford A… Read more »
Possible that he suffered small degree of cerebral ischemia and was having the resultant weirdness.
Hi Scott..
I remember last time when I had a patient with AD I used IV Labetalol but it did not work..and finally when Cardiology Residents admitted him they said its dissection you can’t do anything about the BP and he started a GTN drip at 2.5mcg!!
Uggggg!
[…] on Treatment of Aortic Dissection (posted Jan. […]
Scott,
Thanks for this awesome review of agents for treatment of AD. Often making/suspecting the diagnosis is a greater challenge than controlling dP/dt.
Had recent case of 44 yo short-stature Asian male with no PMH and CC of mild epigastric pain completely resolved with one bolus of 25 Fentanyl while initiating work up for presumed dyspepsia. No ETOH hx. Vitals normal. And, oh by the way slight numbness one leg resolved prior to arrival.
D-dimer ordered in error by unit clerk was 15 ug/mL
(0-0.5 nl). Of course, CT showed Type A dissection on CT scan. Pt did well afer surgery, but often freaks me out how minimal and non-specific initial symptoms can be.
Love to hear your take on utilitiy of D-dimer as screen for AD. Heard recent Essentials talk that not a reliable screen, but hard to CT every non-specific abdominal pain, particularly in otherwise healthy young patients.
While perhaps not perfectly sensitive, my experience is best to pay attention to super high d-dimer results.
I think your observations jibe with mine, but until there is published data we can’t determine the variable specificity of high d-dimers. Until ACEP or AHA write a clin. policy stating a negative d-dimer rules out AD in low risk patients, I would be wary to use it that way.
Have not seen any articles showing clevidipine being associated with different outcomes vs. nicardipine. Other than being slightly easier infuse, we don’t use it because it is expensive and is prepared in a lipid emulsion with the same issues of prolonged infusion as propopfol.
It is because it is expensive that nicardipine remains on the market. When clevidipine costs the same, nicardipine disappears. The problems with prolonged propofol relate to prop infusion syndrome; I look at the lipids as a plus.
Scott
Great Podcast as usual. Question, comment and case.
1. In the woman who upped her BP with withdrawal of 4 ml of blood, do you think the bump might have been related to a catecholamine surge from the porcedure?
2. I’ve seen about 15 TAD’s over the years and most are the ones the nurses make snide remarks as they put the chart in the rack. You know, “This lady is acting like a big time drug seeker, saying she has chest pain, back pain, Abd pain and she’s just acting crazy.
3. Had a 30 Y.O male, smoked, no other risk factors. Had classic ACS symptoms and an EKG that showed inferior STEMI. Nothing to suggest TAD. Activated cath lab, started all the usual, including heparin, and then looked at the CXR. Mediastinum was wider than I was comfortable with so, I sent him over for a stat CTA before the cath lab arrived. Looked at the images. Dude was dissecting from stem to stern. Had protamine on way from pharmacy and Surgery team en route by the time he arrived. Did OK, Lucky him, AND Me!
[…] you will have already listened to Scott Weingart’s talk on EMCRIT on Mx of Aortic dissection. There are a few differences in opinion on which drugs to use, and Scott talks about some drugs […]
Hi Scott, Just got around to this one now – great talk. In our ICU (I’m ED/ICU doctor in Australia), the only IV antihypertensives we have are esmolol (which we are actively discouraged in using because of $$), gtn, and snip… we will also often use IV labetolol infusions and Hydralazine infusions. I hadn’t heard the argument that labetolol has more negative inotropy than negative chronotropy, but I can say in my little experience it rarely achieves a good beta-blocking effect and always requires supplemental treatment. We have no short-acting dihyrdopyrdines at all. However, this said: everyone I work with clinically argues against esmolol alone as a starting therapy. The physiological reason being that hypertension (often extreme) in unruptured dissection is commonly due to poor renal blood flow. This means that the systemic vascular resistance is already maxed out because of the powerful RAA activation trying to get blood passed the point of dissection. The heart rate has increased both from sympathetic drive and to maintain cardiac output in the presence of high SVR. By administering a beta-blocker, one could theoretically increase SVR by an unopposed beta-2 receptor blockade within the peripheral vasculature. They argue in my unit that with… Read more »
Cynthia, I’m not sure I understand their arguments at all. The bedrock of management of both dissection and traumatic rupture is to limit how many beats hit the area of aortic disruption. Any theoretical problem with beta-2 will be addressed with a vasodilator if the pressure is not addressed by esmolol alone.
Late clarification: esmolol has no effect on beta-2 (very minimally at high/supratherapeutic doses). Theory is not plausible with typical esmolol use.
[…] Commento personaleLa prima considerazione da fare è che, per quanto mi è dato di sapere, la nicardipina nella formulazione endovena non è disponibile in Italia. Allora perchè interessarsi a questo articolo?Il motivo secondo me è duplice. Il primo è che la nicardipina sta prendendo sempre più piede come farmaco da utilizzare sia nelle emergenze ipertensive, sia in alcune situazioni come la dissecazione aortica, prendendo il posto del meno maneggevole nitroprussiato. Si veda al riguardo, o meglio si ascolti, il post di emcrit sull’argomento https://emcrit.org/podcasts/aortic-dissection/ […]
[…] months podcast is on theTreatment of Aortic Dissection from managing the BP, through to tubing the dissecting patients, Scott covers it […]
[…] https://emcrit.org/podcasts/aortic-dissection/ […]
[…] For Higher Speciality trainees you might want to listen to the EMCRIT take on aortic dissection management […]
Do you have any data/gestalt on how common a presentation of primarily stroke is?
I had a case of a male in his mid 60’s, I believe, who presented with profound dysphasia. He was not able to communicate effectively, but he did gesture towards his chest/shoulder as if in pain. 12-lead unremarkable. Clear time last seen asympomatic of < 30 minutes.
The story came to light from family shortly after arriving at the ED that he complainied of back pain and had near-syncope just prior to calling EMS. This prompted work-up for dissection which was found from his aortic valve to his iliac bifurcation with involvement of at least one carotid.
This case, though somewhat recent, has made me more wary of stroke with any possibility of chest/back pain for a possible diagnosis of dissection. Do you think this is something reasonable to keep in mind, or do you think I had a unique case?
Thanks!
it is rare, but we have all seen this. If they have chest pain, we usually add chest imaging with contrast prior to lytics. The scary ones are the ones who are chest pain-free. You are kind of hosed in these cases.
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You mentioned that you could not do a thoracotomy on the case involving the woman with tamponade, instead choosing to do a pericardiocentesis. Is there a reason you could not do the thoracotomy? I thought tamponade was one of the indications for performing a thoracotomy in the ED.
Thanks! Love the podcasts.
doing a thoracotomy in a patient backbleeding from a dissection will cause exsanguination as opposed to a pt with a ventricular stab wound which can be stopped with a finger
[…] EMCRIT – https://emcrit.org/podcasts/aortic-dissection/ […]
[…] EMCRIT – https://emcrit.org/podcasts/aortic-dissection/ […]
[…] For a detailed analysis of aortic dissection medication choices and arguments for esmolol as the first line medication visit EMCrit […]
The other night we had a patient with a dissecting aortic dissection in which nicardipine was maxed out at 15mg/hr and esmolol at 300mcg/kg/min. The patient still needed a smidge more BP control. What would you suggest as the next medication to add on?
options include adding clevidipine, nitroprusside, or hydralazine
[…] EMCrit Podcast 91 – Treatment of Aortic Dissection […]