Aortic Emergencies:True Jeopardy
Meira LouisDr Adam Oster
Ouch, my back! Fat Pipes In real life... Aortic Pics
10 10 10 1020 20 20 2030 30 30 3040 40 40 40
Ouch, my Back! 10 pts
What are type A and type B dissections and what
percentage of dissections account for each?
62% 38%
Name five indications for a surgical approach
Ouch, my Back! 20 pts
When Surgery?
• All Type A
• Type B if:– Persistent pain– Uncontrollable hypertension– Occlusion of a major artery or branch point– Frank leak or rupture– Development of an anurysm
Surgical mortality: 27%Medical mortality: 56%
Surgical mortality: 32%Medical mortality: 10%
Type A repair
Ouch, my Back! 30 pts
What is pseudohypotension
When the intimal flap obstructs the flow to one or more limbs, giving low blood pressure peripherally, but adequate central pressure
Signs and Symptoms• Blood Pressure
– Type A 36%, Type B 70%• Sudden severe sharp chest pain - 73%
– Type A – anterior pain– Type B – back or abdominal pain
• Syncope – 13% of Type A• Abdominal pain
– Type A 22%, Type B 43%• Aortic insufficiency murmur
– Type A 44%, Type B 12%• Pulse Deficits – less than 30%
Demographics• Under 40
– More likely to present without HTN– More likely to have a bicuspid aortic valve or have
had prior aortic valve surgery
Peak time of day - 8-9amPeak time of year – Winter (October-January)
Mehta et al. IRAD investigators. Circulation. 2002; 106(9):1110-1115.
Ouch, my Back! 40 pts
What two parameters are you targeting with medical
management, and what two drugs would you use to help
get you there?
Goal One: dP/dT
• Beta blockers to get your heart rate under 60– Esmolol
• 5g in 500ml of D5W• Bolus 500µg/kg, then infuse
– Labetolol• 20mg IV bolus q5-10 minutes• Then infuse at 1-2µg/min
– If history of bronchospasm/COPD can use β only (metoprolol)
Goal Two: Blood Pressure
• Want to reduce the afterload– Sodium Nitroprusside
• Dont use:– Nifedipine
• Can increase shear stress on wall– Nitroglycerine
• Less effective than nitroprusside
Long Term
Fat Pipes 10 points
At what size does a thoracic aortic aneurysm greatly increase its likelihood of
rupture?
Rates and Measurement
Hinge Points
AAA
Fat Pipes 20 points
DAILY DOUBLE
What is the name of this condition and what causes it?
Blue Toe Syndrome
• Microemboli of cholesterol crystals or clot• Palpable pedal pulses and cool, cyanotic toe
Palpable Mass
Size Felt on exam
3.0-3.9cm 30-60%
4.0-4.9cm 50-70%
>5cm 75-85%
Fat Pipes 30 points
What is the sensitivity of ED ultrasound for detecting abdominal aortic aneurysms?
Overall:• 73 studies reviewed• 4 studies included• All used convenience samples of symptomatic patients• Sensitivity 94-100%• Specificity: 98-100%• No differences by level of training
Fat Pipes 40 points
For an asymptomatic patient with AAA of 4.2cm, does the
evidence support any interventions, other than
imaging follow up?
Smoking cessation is recommended.
Level of recommendation: Strong
Quality of evidence: High
Statins may be considered.Level of recommendation: Weak
Quality of evidence: Low
Doxycycline, roxithromycin, ACE inhibitors, and angiotensin receptor blockers are of uncertain benefit.
Level of recommendation: Weak
Quality of evidence: Low
The use of beta blockers is not recommended.
Level of recommendation: Strong
Quality of evidence: Moderate
Screening for AAA is recommended for first degree relatives of patients with an AAA.Level of recommendation: Strong
Quality of evidence: High
Evolving Research
• Statins – Schouten et al, 2006• ACE inhibitors – Hackam et al, 2006• ARBs – Mochizuki et al, 2007• Antibiotic agents - Mosorin et al, 2001
In real life... 10 points
• 76yo female with 45 minutes of pain radiating to the back
• Chronic HTN, dyslipidemia, osteoarthritis• BP 161/95, HR 117• Bedside U/S is suspicious for a ruptured AAA
What ED management would you undertake?
Ruptured AAA management
• Two large bore IVs• Crossmatched blood (massive transfusion)• BP management
– Permissive hypotension– Need to prevent end-organ damage
• MI, resp failure, renal failure in post-op period– NO evidence that lowering HTN helps
• Surgery
In real life... 20 points• A 72 yo male presented with acute onset of
bilateral lower limb ischemia• Creatinine was elevated at 340• Hb was stable at 154, no evidence of a GI
bleed
Aortocaval Fistula
•Abdominal or back pain•Continuous abdo. bruit (75%)•Palpable abdominal thrill (25%)•High Output CHF signs
• Dyspnea• Jugular venous distension• Pulmonary edema
Aortocaval Fistula
• Dilated superficial veins on legs and abdominal wall• Venous rupture in GI and bladder
• Gross hematuria• Rectal bleeding
• Renal insufficiency
In real life... 30 points
• 43 yo male with history of alcohol abuse• Bright red emesis and melena•BP 80/20, HR 120/min•No meds, no surgical hx, no prior GI bleeds•Normal INR/PTT, platelets•Endoscopy showed clots, but no source of bleeding
Aorto-enteric Fistula
• Third or Fourth segment of the duodenum• Primary vs Secondary• First stage
– Leaking GI contents, abscess• Second Stage
– Erosion of vessels in bowel wall• Third Stage
– Rupture into GI lumen
In real life... 40 points• 72yo male presents with vague , dull
abdominal pain• Intermittent abdominal bruit can be heard• BP 115/85, HR 72 • Underwent successful Dacron endovascular
AAA repair 1 month ago• History of controlled HTN, diabetes, CAD
What must be ruled out?
Endoleaks
Aortic Pics 10 points
Who is this man and what did he die from?
John Ritter
• Collapsed on set in 2003 and died the same day
• Widow sued his radiologist and cardiologist– "Both sides agree that his true condition -- an
aortic dissection, which is a tear in the largest blood vessel in the body -- was not identified until right before his death.“
Aortic Pics 20 pts
Name the following sign:
-widening aortic knob- widening of mediastinum- widening of descending aorta- widening of ascending aorta- parasternal shadow widening
-pleural effusion- tracheal shift
-blurring of aortic knob- localising lump on aortic arch distal to great vessels
-displacement of intimal calcification >6 mm
Chest Film
CT
Other Modalities
• TTE• TEE• MRI
Aortic Pics 30 points
On the morning of 25 October 1760, this man entered his
water closet and, after a few minutes, his valet heard a
loud crash. The valet entered the water closet to find him on the floor. He was lifted
into his bed, and asked for his daughter, but before she
reached him, he was dead.
A) William IIIB) George IIC) Adam I
D) Henry VI
King George II of England
Died of a Thoracic Aortic Dissection
DAILY DOUBLE
Aortic Pics 40 points
• A 69-year-old white male scientist consulted his physician because of pain in the upper abdomen. For a number of years he had suffered from attacks of upper abdominal pain, which usually lasted for 2-3 days and were often accompanied by vomiting. These attacks usually occurred about every 3 or 4 months.
• The patient was a pipe smoker and slightly overweight. The rest of his history was noncontributory. On physical examination, his physician noted a pulsating mass deep in the center of the abdomen.
Which famous scientist died of a ruptured aortic aneurysm?
Albert Einstein
• Exploratory laparotomy in 1948 showed a “grapefruit sized” mass• Experimental surgery by Dr R. Nissen•Polythene cellophane
• Died five years later of rupture