How is acute aortic dissection (AAD) in the emergency department (ED)?

Updated: Nov 09, 2018
  • Author: John M Wiesenfarth, MD, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Answer

The mortality rate of patients with aortic dissection is 1-2% per hour for the first 24-48 hours. Initial therapy should begin when the diagnosis is suspected. This includes 2 large-bore intravenous lines (IVs), oxygen, respiratory monitoring, and monitoring of cardiac rhythm, blood pressure, and urine output.

Clinically, the patient must be assessed frequently for hemodynamic compromise, mental status changes, neurologic or peripheral vascular changes, and development or progression of carotid, brachial, and femoral bruits.

Note the following:

  • Aggressive management of heart rate and blood pressure should be initiated.
  • Beta blockers should be given initially to reduce the rate of change of blood pressure (dP/dt) and the shear forces on the aortic wall.
  • The target heart rate should be 60-80 beats per minute.
  • The target systolic blood pressure should be 100-120 mm Hg.

End organ perfusion should be evaluated. Balancing the risks of dP/dt on the aortic wall versus the benefits of acceptable end organ perfusion may be a difficult clinical decision.

Aortic dissection associated with cocaine ingestion is challenging. It has been argued that using beta blockers alone without any simultaneous alpha blockers may allow unopposed alpha aderenergic vasoconstriction, potentially worsening myocardial ischemia. Therefore, it is recommended labetalol be used as it has both alpha- and beta-blocking properties.

Retrograde cerebral perfusion may increase the protection of the central nervous system during the arrest period.

Up to one third of patients with acute aortic dissection may have their diagnosis missed. [3]  Factors that contribute to an initial missed diagnosis of aortic dissection include female sex, the absence of back pain, and/or the presence of extracardiac atherosclerosis. Patients whose aortic dissection was initially missed also tend to have more imaging studies and longer time to surgery; however, these do not appear to affect adjusted long-term all-cause mortality. [3]

Magnetic resonance angiography (MRA) may help in the evaluation of, and guide management of, suspected acute aortic dissection in patients with contraindications to compute tomography angiography (CTA) in the emergency department. [4]


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