What about the signs and symptoms? Chest pain,
tearing, radiating to the back. Doc, well this
thing hurts on a scale of 1 out of 10, 10 being the
worst pain the patient has ever experienced, it is a 10, radiating
to the back, severity and intensity. Sudden
onset because of dissection. What about the
patient’s unequal blood pressure where?
I just told you the robbing the blood because
of the dissection it is removing the blood.
Not removing the blood, you are losing the
blood literally. Unequal blood pressure in
both arms due to dissection, obstruction of
branches of the aorta. You have issues there
because of dissection. Look for that, please.
The most rapid means of providing sufficient detail
to proceed directly
to the operating room is with the trans
for hemodynamically unstable patients,
but requires procedural sedation,
which may have adverse effects.
A TEE is fast, minimally invasive,
and can be used in unstable patients
or those with renal insufficiency
or contrast allergy. Patients
who are stable enough to go to a CT
scanner from the emergency department
more commonly get a CT for diagnosis
of aortic dissection.
This requires contrast injection
the diagnosis of aortic dissection
by CT requires identification
of two distinct lumens,
and the intimo flap may
or may not be seen.
A magnetic resonance angiogram
is another imaging test that may be used
in hemodynamically stable patients.
Diagnosis made by CT and on this particular
CT you will notice right in the middle where
there is a tear of your aorta resulting in
blood quickly leaking out and resulting in
all kinds of issues including that unequal
blood pressure between the arms to the point
where maybe there is the pericardial cavity effusion
or in other words rapidly there might be a
tamponade and that is exactly what the middle
portion of the CT is then showing you.
Diagnosis. Control of blood pressure. Usually,
ICU, IV nitropusside and perhaps you are thinking
about esmolol or other IV beta blockers because
you are trying to control that bleeding that
is now taking place quite a bit. You don’t
want that cardiac output to be quite high because
that is then going to then contribute to the
blood being lost through the dissection. That must
be understood. You want to relax the heart
so that you have control of the dissection.
Medical management. The only one that I will
be point out here to you will be Stanford type A.
A is ascending type of dissection. It is persisitent pain,
persistent dissection which then requires immediate surgery.
B, distal, by the thoracic and descending aorta.