see also: [[tamponade]] > case: [Bloating = type B dissection](https://www.medscape.com/viewarticle/bloating-or-aortic-tear-68-year-olds-shocking-diagnosis-2025a1000iic) > [!Key Points] > - severe chest pain with normal ECG, consider dissection > - **Chest pain PLUS...** > - lower HR first, then lower BP (or just use labetalol) - Ascending (+/- descending also): type A -- surgery - Descending only (distal to origin of left subclavian): type B -- often medical > [!tldr] research highlights > - [DAShED BMJ 2023](https://www.stemlynsblog.org/the-dashed-study/) > - Rare condition (3% of CTs positive) and decision tools are bad > - [needle in haystack commentary](https://emj.bmj.com/content/41/3/134) # Risk factors - HTN - atherosclerosis - coarctation of aorta (younger patients) - peek incidence age 40-70 - Connective tissue disease - Marfan's - less common: ehleros danlos - aortic valve disease (eg bicuspid) - aortic aneurysm - drugs ([[Cocaine]]) - coronary angiogram # life threatening complications 1. cardiac tamponade (most common) 2. Acute aortic incompetence (aortic regurgitation, aortic insufficiency, or a leaky aortic valve) 3. dissection **into coronary artery** (often *RCA*) --> inferior MI 4. stroke # Signs and symptoms - acute onset tearing/ripping pain (can be like the SAH of chest pain!) - usually present hypertensive (ominous if hypotensive) - rarely Beck's triad (hypotension, elevated JVP, quiet heart sounds) - ECG can be normal or show features of acute ischemia - Other changes may show [[STEMI ECG patterns#Inferior MI]] or [[STEMI mimics|LVH]] changes - pulse deficits (if disceting up into another vessel in aortic arch ![[Pasted image 20230519165354.png]] Type A dissection # Treatment - reduce rate (reduce sheering stress) and THEN lower BP - ?labetalol for both **Aim HR 60** - metoprolol 1-2.5mg IV boluses repeat Q3-5 min - [[labetalol]] 5-20mg IV boluses Q5-10 minutes - infusion 20-160mg/hour (0.5-2mg/min) - esmolol 500 mcg/kg over 1 min loading dose - slow IV 50 mcg/kg/min over next 4 min - infusion 50-200 mcg/kg/min - propranolol - 1-3mg IV Q5min Calcium channel blockers (dilt and verapamil) 2nd line if cannot give beta blockers **Aim systolic BP 100-110mmHg** - labetalol - GTN infusion 5-50mcg/min - increase by 3-5 mcg/min Q 3-5 min as required - Sodium Nitroprusside (comes in 50mg ampoules) - 0.25 mcg/kg/min initial rate - titrate to response every 2-3 min up to 10 mcg/kg/min - **>2.5 mcg/kig/min** for >4 hours can cause cyanide toxicity - hydralazine -- longest acting so least preferred - 5-10mg IV over 5-10 min - repeat every 15-20 min PRN # Aortic dissection risk score - any high risk condition (marfan syndrome, family history, known aortic valve disease, recent surgery, known aneurysm, [[Pregnancy physiological changes |pregnancy]]) - any high risk pain feature (chest, back, or abdominal pain described as abrupt onset, severe intensity, or ripping/tearing) - any high risk exam feature (evidence of perfusion defect eg pulse defect or systolic BP differential, focal neuro deficit, new aortic insufficiency murmur, hypotension/shock score 0-1 - D dimer cutoff <0.5 score >1 - consider going great to CTA # Related Questions ## aortic dissection - [x] 1Q: [Aortic dissection](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=2) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=1) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=2) - [x] 2Q: [Chest and interscapular pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=14) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=12) - [ ] 3Q: [Aortic Dissection](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=64) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=24) - [ ] 4Q: [Aortic Dissection](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=59) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=25) - [ ] 5Q: [Aortic Dissection](x-devonthink-item://D466AD93-18B7-467C-BB6E-192EEBE26935?page=11) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=4) - [ ] 6Q: [If Time is Money This Guy is Broke](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=48) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=30) - [ ] 7Q: [Chest Pain](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=13) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=9) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=4) ## chest pain - [ ] 8Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=11) - [ ] 9Q: [Chest pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=21) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=21) - [ ] 10Q: [Pericardial Effusion](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=57) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=37) - [ ] 11Q: [Pericardial Effusion](x-devonthink-item://F0CF1E99-6E8D-4E3C-9C45-046E93F30DBA?page=17) -- [Answer](x-devonthink-item://E437B768-E942-4349-941C-A97410E4E28F?page=12) ## dissection - [x] DUPLICATE Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) ## tamponade - [ ] 95Q: [Pericardial tamponade](x-devonthink-item://71171BE8-7F92-40FA-99D2-0FF4C482F766?page=4) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=17) - [x] DUPLICATE Q: [Pericardial Effusion](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=57) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=37)