9/18/2017 1 Aortic Emergencies Carrie Fales, MD Steven Nakajima, PharmD No Financial Disclosures ED or No ED? Objectives AAA and Aortic dissections Overview Classification/Pathophysiology Diagnostics Management Disposition Who is in the audience? Are you a: A. Nurse B. Paramedic C. Physician D. NP or PA E. Respiratory therapist F. Pharmacist G. Other Aortic Emergencies Abdominal Aortic Aneurysm (AAA) Aortic Dissection
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Also consider cardiac enzymes, LFTs, lipase, UA with other diseases in differential
EKG
Diagnostic Studies
X-ray Rarely can see calcification
Used to identify alternative diagnoses
Diagnostic Studies
CT
Nearly 100% sensitive and specific
Can detect extra luminal blood Retroperitoneal hemorrhage identification 77-
100% sensitive
Helpful for surgical planning
Radiation
Time consuming
Not ideal for unstable patient
IV contrast not necessary but does provide more information
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Diagnostic Studies
Ultrasound
ED bedside US ideal
Advantages Readily available Very sensitive and specific Lack of radiation
Disadvantages Operator dependent Inadequate to identify retroperitoneal blood, most
common area of AAA rupture
Bedside Ultrasound
Use 3.5 MHz curvilinear transducer
Measure outer wall to outer wall
Measure proximally and distally
Transverse (9 o’clock) and sagittal/longitudinal (12 o’clock) planes
If AAA found, look for free fluid with FAST
Biggest hurdles Bowel gas Obesity IVC vs. aorta
Transverse Proximal
Transverse Distal
Sagittal/Longitudinal Proximal
Sagittal/Longitudinal Distal
Treatment and Disposition
Surgical emergency
Early surgical evaluation and involvement
Resuscitate hypotensive patients with blood products
Treat hypertension with beta blockers
Question #1
The majority of isolated AAAs are infrarenal in location.
a. True
b. False
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Question #1- Answer
The majority of isolated AAAs are infrarenal in location.
a. True
b. False
Question #2
All of the following are risk factors for aortic aneurysm EXCEPT:
a. Hypertension
b. Age over 65
c. Cigarette smoking
d. Atherosclerosis
e. Diabetes
Question #2- Answer
All of the following are risk factors for aortic aneurysm EXCEPT:
a. Hypertension
b. Age over 65
c. Cigarette smoking
d. Atherosclerosis
e. Diabetes
Question #3
In what percentage of patients presenting with abdominal aortic aneurysm is an alternative, incorrect diagnosis initially made by physicians?
a. 10% b. 30% c. 50% d. 80%
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Question #3- Answer
In what percentage of patients presenting with abdominal aortic aneurysm is an alternative, incorrect diagnosis initially made by physicians?
a. 10% b. 30% c. 50% d. 80%
Question #4
The absence of a pulsatile abdominal mass excludes the diagnosis of aortic aneurysm.
a. True
b. False
Question #4- Answer
The absence of a pulsatile abdominal mass excludes the diagnosis of aortic aneurysm.
a. True
b. False
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Aortic Dissection Aortic Dissection
Subset of acute aortic syndromes Aortic intramural hematoma
Penetrating atherosclerotic ulcer
Aortic dissection
Aortic Dissection
Aortic dissection diagnosis missed in ED setting 16-38% of the time More likely to be missed for walk-in patients compared to EMS
arrived patients
Area for medical risk and litigation
High morbidity and mortality Type A Dissection
1-2% mortality per hour in first 48 hours 50% mortality day three 80% mortality day fourteen
Type B dissection 10-70% mortality at day 30 based on risk factors and medical co-
morbidities
Aortic Dissection
2/3 of aortic dissections are Stanford type A
1/3 of aortic dissections are Stanford type B Approximately 30% will be classified as complicated
dissections radiographic evidence of thoracic aortic rupture (eg, blood
outside the aortic wall)
ischemia involving the viscera, kidneys, spinal cord, or lower extremities
persistent pain
rapid expansion in the distal arch or proximal descending aorta to a total aortic diameter of > 4.5 cm
Classification
Acute vs chronic
14 days of symptoms
DeBakey type I, II, or III
I- ascending aorta, arch, descending aorta
II- only ascending aorta
III- only descending aorta
Stanford A or B
A- any involvement of ascending aorta
B- only descending aorta
Classification
Class 1 – classic aortic dissection: separation of intima from media and/or adventitia with intimal flap
Class 2 – intramural hematoma: hemorrhage within aortic wall without obvious intimal flap
Class 3 – subtle-discrete dissection: localized intimal tear with no dissection flap or medial hematoma
Class 4 – penetrating atherosclerotic ulcer: usually localized to descending aorta with significant atheroma; found usually in the adventitia with localized hematoma or saccular aneurysm. May convert to classic aortic dissection
Class 5 – iatrogenic or traumatic dissection: following cardiac catheterization or cardiac surgery or decelerating chest trauma
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Aortic Dissection
Approximately 10,000 patients in US per year Likely underestimate because of retrospective data and
autopsy data
Most commonly 40-70 year olds
Men 3x more likely than women
Women tend to present later and with worse outcomes