Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL!  Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%.

Recognition

• Sudden pain  –  site varies and could be one or more sites; jaw, head, chest, back, abdomen pain [85%] 
• Migrating pain (as the flap extends) [20%]
• Signs of organ injury (e.g. MI, Stroke, Abdo pain)
• Pulse deficit [15-30% but pathonomonic]
• NEW Aortic Regurg [12-44%]
• Cardiac Tamponade
• Shock/Collapse

Investigations – CT

• CT: Diagnostic and is the test of choice [however early dissections can be missed]
• D-Dimer: Often has a significant and rapid elevation -BUT not sensitive enough to rule out!
• Troponin: Can be elevated
• ECG: May show Myocardial Infarction (MI)
• Ultrasound: May show tamponade
• CXR: May show wide mediastinum – BUT is a not a reliable rule out!

Treatment

There are 3 types of dissection; A – Involving the Ascending or Arch, B – Only involving descending, Intramural Haematoma – theres blood in the wall but no flap or flow seen. ALL 3 are emergencies and from our point of view they are ALL treated the same.

1. REFER to Cardio-Thoracic surgeons [Leeds] – Ensure images have been linked
2. Reduce sheering stress on the aorta
   • Blood Pressure and Heart Rate control – IV Labetalol [aim SBP 100-120mmHg]
   • Pain Control – Opiates

The surgical management varies depending on, the type and clinical features (e.g. open surgery, endovascular, conservative). However, this needs to be the decision of the Cardio-Thoracic Team, and they should inform you of their plan (e.g. blue light transfer or manage medically on CCU).

 

Cardiac Tamponade

This is  a complication of aortic dissection esp. type A, but its management has been controversial. Older studies having shown increased mortality with pericardiocentesis. However, the European Society of Cardiology 2015 recommended that “controlled pericardial drainage” may be a useful bridge to surgery(only removing enough blood to maintain an SBP of 90mmHg), in those too unstable to survive transfer to theatre. Practical guide from ESC HERE.

 

References

• Improving outcomes in acute aortic dissection – Bristol Royal inf.
• European Society of Cardiology – 2015 ESC Guidelines for the diagnosis and management of pericardial diseases
• RCEM Learning