A 50-year-old man presented with 3 hours of central chest pain. Initial investigations revealed a blood pressure of 90/60 and a normal ECG. A CT angiogram showed an intimal tear and dissection in the aortic arch. The patient was transferred urgently for surgical repair of a type A aortic dissection. Aortic dissection is a tear in the aortic wall that can propagate and cause complications if not treated. Diagnosis is made through imaging like CT scans. Emergent management involves stabilizing the patient's blood pressure and transferring patients with type A dissections for surgical intervention.
2. Case presentation
50 yo man BIBA at 0230 with 3 hours of
dull non-radiating central chest pain.
En route, administered O2, 300mg
Aspirin, 10mg Morphine and 10mg
Metoclopramide
Pain free on arrival.
3. Previously well
No positive risk factors for IHD or PE
No regular medication or other drug
use
No trauma or recent infections
4. No prior episodes of chest pain
Vomited twice at home, and described
as clammy and pale on arrival of
ambulance, with BP 90/60 supine.
5. On arrival
Pale
Temp 37 HR 60
BP 60/40mmHg RR 14
O2 sat 100% (3L/min)
GCS 15/15
Equal radial pulses
4/6 Systolic murmur
Lungs clear to auscultation
9. Course
2nd ECG normal and Trop T < 3 at 6
hours post onset of pain
2nd litre of saline running, BP still
90/60mm/Hg, HR 60/min, with normal
peripheral perfusion
BP both arms the same
Chest pain “2/10”
Decision to order CT angiogram of chest
13. Relatively uncommon (2.6-3.3/100 000 person-
years)
Initial event in aortic dissection is a tear in the
aortic intima.
Propagation of the
dissection may be
1. Proximal (retrograde)
2. Distal (antegrade)
14. Complications
Aortic valve injury with regurgitation
Pericaridal tamponade
End organ ischemia, examples
include syncope, CVA, mesenteric
or renal ischaemia.
15. Risk factors for aortic dissection
Advancing age
Male sex 2:1 (Female – pregnancy)
Systemic hypertension
Pre-existing aortic aneurysm
Atherosclerosis
16. Risk factors for under age 40
Collagen vascular disorders
Vasculitis
Bicuspid aortic valve
Aortic coarctation
Turners syndrome
Marfan syndrome
Prior aortic valve surgery
Instrumentation
Trauma
High intensity weight lifting or other exercise
Cocaine
17. Classification
Stanford
Type A –ascending Aorta
Type B – all other types / sites in aorta
DeBakey
Type I – Originates in ascending aorta,
propagates at least to the aortic arch and
often beyond it distally.
Type II – Originates / confined to the
ascending aorta.
Type III – Originates in descending aorta,
rarely extends proximally but will extend
distally.
18.
19. Diagnosis
Routine bloods – non diagnostic
D-dimer < 500ng/ml unlikely to be dissection
History
Anterior chest pain in ascending aortic
dissection
Severe sharp or tearing posterior chest or
back pain when the dissection progresses
distal to the subclavian artery
20. Pain can associated with
Syncope
Stroke
MI
Heart failure
End organ ischemia (splanchnic, renal,
extremity or spinal cord ischaemia)
Hypertension common with type B
Hypotension
21. Diagnosis of aortic dissection depends
upon demonstration of the dissection on
imaging studies
CXR
CT
MRI
TEE / TTE