0071643192.pdf

■ Involving spinal cord artery →paresis

■ Involving other major branches →limb or organ ischemia

■ May ultimately empty back into true lumen of aorta, or rupture through

adventitia

SYMPTOMS

■ Severe chest, neck, or back pain

■ Present in >90% of patients

■ Classically described as “ripping” or “tearing” but actually more com-

monly described as sharp (64%)

■ Abrupt and maximal in onset (85%)

■ Anterior chest pain more common (73%) than posterior chest pain

(36%) or back pain (53%), although this varies depending on whether

it is a Type A dissection (anterior chest pain more common) or Type B

dissection (back pain more common)

■ May migrate as dissection progresses

■ Dissection into distal aorta =abdominal or flank pain

■ Nausea, vomiting, diaphoresis

■ Syncope (5–10% of patients)

■ Neurologic symptoms (5%): If carotid or spinal artery involvement

■ Mental status change, stroke symptoms, paresis

EXAM

■ May be surprisingly normal

■ Hypertension: Common unless tamponade or rupture present

■ Normal or low BP does notexclude dissection.

■ If subclavian artery involved: Asymmetric pulses (or BPs). This is a relatively

rare finding (15%).

■ If proximal dissection, may find

■ Shock and hypoperfusion (tamponade)

■ New murmur of aortic regurgitation ±CHF

■ If involving carotid or spinal arteries, may find

■ AMS, stroke symptoms, paresis

DIFFERENTIAL

■ Includes acute coronary syndrome, PE, pneumothorax, ruptured aneurysm,

esophageal perforation

DIAGNOSIS

■ Suspect diagnosis in any patient presenting with chest pain, especially

patient with history of uncontrolled HTN (or other risk factors), shock,

or associated neurologic symptoms.

■ ECG

■ To exclude coronary artery involvement (inferior ischemia indicating

RCA involvement)

■ LVH is common finding (26%).

■ Small portion (<5%) of acute aortic dissection will have new Q waves

or ST segment changes.

■ CXR(vast majority, >85%) will have some abnormality (See Figure 2.18)

■ Widened mediastinum (62%)

■ Loss of aortic knob (50%)

■ Pleural capping

■ Aortic shadow extending >5 mm from aortic calcification (14%)

CARDIOVASCULAR EMERGENCIES

Pain (chest, neck, or back) is

present in the vast majority of

patients with aortic dissection.

Patient with chest pain and

stroke symptoms?

Consider aortic dissection!

A new aortic regurgitation

murmur in a patient with

acute chest pain is highly

suggestive of proximal aortic

dissection.

Asymmetric pulses (or BP) will

occur only if the subclavian

artery is involved.