Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

140 Aortic Dissection

Aortic Dissection....................................

KENDRICK A. SHUNK, MD, PhD

history & physical

History

■Hypertension, Atherosclerosis, Cystic medial necrosis (Marfan’s

Ehlers-Danlos, others)

Signs & Symptoms

■Severe anterior or posterior chest pain often described as “ripping” or

“tearing”, often radiating to intrascapular region and migrating with

the propagation of the dissection, diaphoresis, syncope, weakness,

dyspnea, hoarseness, dysphagia

■Hypertension or hypotension

■Aortic regurgitation (occurs in 50% of type I dissections)

➣Diastolic AR murmur

➣Widened pulse pressure, bounding pulse

■Loss of pulses

■Pulmonary rales

■Neurologic findings

➣Hemiplegia, hemianesthesis (carotid occlusion), paraplegia

(spinal artery occlusion), Horner’s syndrome

tests

■Basic blood tests:

➣Often non-contributory

■Specific diagnostic tests:

➣ECG

Usually no ischemia (rarely acute MI from extension into RCA

or Left main)

Low voltage: suspect hemopericardium

➣CXR

May show widened mediastinum and/or left pleural effusion

■Other imaging tests

➣Transthoracic echocardiography successful at identifying 70–

90%

➣TEE and CT and MRI all offer excellent sensitivity (∼98%)

TEE has lesser ability to fully define aortic arch anatomy

CT and MRI require movemement of critical patient out of ICU

Common practice: pursue all three, take first available