01Approach to the Critical Patient/attcp60

Immediate priorities

›Life threats at presentation

›Untreated mortality 1 to 2 percent per hour in first 24 hours

›Surgical emergency

›Cardiothoracic surgery activation before confirmatory labs

›Hemodynamic collapse mechanisms

›Cardiac tamponade from rupture into pericardium

›Free rupture into pleura or mediastinum

›Acute severe aortic regurgitation

›Malperfusion threats

›Coronary ostial compromise causing acute MI

›Carotid involvement causing stroke

›Spinal malperfusion causing paraplegia

›Airway and breathing

›Oxygenation target

›SpO2 94 to 98 percent

›Avoid hypoxemia worsening malperfusion

›If pulmonary edema from acute AR, prepare ventilatory support

›Diastolic decrescendo murmur

›Rising work of breathing

›Circulation

›Two large bore IV lines

›Bilateral upper limb access

›Account for pulse deficit limb

›Arterial line for accurate titration

›Cannulate limb with higher pressure

›Continuous beat to beat monitoring

›If hypotensive, suspect tamponade or rupture

02History/hx72

Pain characteristics

›Onset and quality

›Abrupt maximal-at-onset pain

›Thunderclap character

›Classically tearing or ripping

›More commonly reported as sharp or stabbing

›Pain location

›Anterior chest pain most common in Type A at 71 percent

›Back pain in 47 percent

›Abdominal pain in 21 percent

›Migratory pattern

›Pain moves as dissection propagates

›Interscapular radiation

›Distinguishing features

›Absence of pleuritic quality

›Helps separate from pericarditis

›Helps separate from PE

›Absence of positional component

›Argues against pericarditis

›Absence of gradual crescendo pattern

›Argues against acute coronary syndrome

Associated symptoms

›Cardiovascular and neurologic

›Syncope present in about 13 percent

›Suggests tamponade

›Suggests cerebral malperfusion

›Focal weakness or numbness

›Carotid involvement

03Physical Exam/exam52

Vitals and perfusion

›Blood pressure assessment

›Hypertension common at presentation

›Sympathetic surge

›Chronic uncontrolled disease

›Hypotension is an alarm finding

›Rupture

›Tamponade

›Severe AR

›Interarm differential above 20 mmHg

›High-risk finding

›Arch branch vessel involvement

›Pulse examination

›Bilateral radial femoral and pedal pulses

›Pulse deficit present in about 30 percent

›Asymmetry localizes branch involvement

›Cool mottled or pulseless limb

›Limb malperfusion

Cardiac and systemic exam

›Cardiac auscultation

›New diastolic decrescendo murmur

›Acute aortic regurgitation

›Wide pulse pressure

›Muffled heart sounds

›Pericardial effusion

›Pulsus paradoxus above 10 mmHg

›Tamponade physiology

›Inspiratory SBP drop

04Differential Diagnosis/ddx34

Life-threatening mimics

›Cardiopulmonary emergencies

›Acute coronary syndrome and STEMI

›ICD-10 I21.9

›Crescendo pain not maximal at onset

›Most common misdiagnosis

›Pulmonary embolism

›ICD-10 I26.99

›D-dimer elevated in both PE and dissection

›CTA distinguishes

›Tension pneumothorax

›Unilateral breath sounds

›Tracheal deviation

›Pericardial and esophageal

›Pericarditis and tamponade

›Positional pleuritic pain

›Diffuse ST elevation and friction rub

›Tamponade may be a complication of dissection

›Esophageal rupture Boerhaave

›Post-emesis onset

›Subcutaneous emphysema

Other considerations

›Vascular and valvular

›Acute aortic regurgitation other causes

›Endocarditis

›Prosthetic valve failure

›Stroke when neurologic deficit dominates

›Consider dissection in young stroke

05Laboratory Tests/lt34

Diagnostic and prognostic labs

›D-dimer

›High sensitivity around 94 percent

›Value below 500 ng/ml in low-risk patient effectively rules out dissection

›Value above 1600 ng/ml strongly suggests acute aortic syndrome

›Limitations

›Not a standalone rule-in

›Combine with risk score

›Troponin

›May be elevated from coronary malperfusion or demand ischemia

›Elevated troponin does not exclude dissection

›Must not delay imaging

›Alerting triad for acute aortic syndrome

›Normal ECG

›Normal troponin

›Elevated D-dimer

Perfusion and preoperative labs

›Malperfusion markers

›Lactate

›Elevated in mesenteric or limb ischemia

›Metabolic acidosis on ABG

›Creatinine and electrolytes

›Renal malperfusion

›Baseline for contrast

›Liver function tests

›Hepatic malperfusion

›Preoperative panel

›Complete blood count

06Diagnostic Tests/dt73

Scoring Systems

›Aortic Dissection Detection Risk Score ADD-RS

›Three category framework scored 0 to 3

›High-risk predisposing conditions

›High-risk pain features

›High-risk exam findings

›Interpretation with D-dimer

›ADD-RS at most 1 plus D-dimer below 500 ng/ml gives sensitivity 93 to 99.8 percent

›ADD-RS of 2 or more warrants definitive imaging

›Evidence

›Endorsed by 2022 ACC/AHA aortic disease guideline

›Supported by 2021 chest pain guideline

›ECG as adjunct

›Neither sensitive nor specific but essential for ACS mimicry

›About 60 percent of Type A have abnormal ECG

›ST depression or T-wave inversion in about 47 percent

›High-risk ECG findings

›ST elevation in 4 to 22 percent may mimic STEMI

›ST elevation in aVR associated with mortality OR 4.85 to 5.30

›Low voltage or electrical alternans suggests effusion

MRI

›MR angiography role

›High diagnostic accuracy

›Sensitivity and specificity above 95 percent

›No ionizing radiation or iodinated contrast

›Acute setting limitations

›Long acquisition time impractical for unstable patients

›Limited monitoring access in scanner

07Disposition/dispo29

Level of care

›Universal admission

›All confirmed or suspected Type A require admission

›No outpatient management pathway

›Operative repair is standard of care

›ICU admission

›Continuous hemodynamic monitoring

›Postoperative critical care

›Admission and escalation criteria

›Confirmed Type A dissection

›Immediate operative planning

›Anti-impulse therapy continuation

›Complicated features

›Hemodynamic instability

›Malperfusion syndrome

›Tamponade or new neurologic deficit

Consultation and transfer

›Surgical consultation

›Immediate cardiothoracic surgery on suspicion

›Do not delay for confirmatory labs

›Parallel resuscitation and imaging

›Multidisciplinary discussion when surgery prohibitive

›Extreme frailty

›Severe comorbidity burden

›Transfer indications

›Absence of on-site cardiothoracic capability

›Transfer to high-volume aortic center

›Stabilize before transport

08Treatment/t79

Immediate anti-impulse therapy

›First-line intravenous beta blockade

›Esmolol infusion

›500 mcg/kg IV bolus over 1 minute

›50 mcg/kg/min continuous infusion

›Titrate by 50 mcg/kg/min to max 200 to 300 mcg/kg/min

›Labetalol

›20 mg IV bolus

›Repeat 20 to 80 mg every 10 minutes

›Or infusion 1 to 2 mg/min

›Targets

›Heart rate 60 to 80 beats per minute

›Systolic blood pressure 100 to 120 mmHg

›If beta blockers contraindicated

›Non-dihydropyridine calcium channel blocker

›Diltiazem IV

›Verapamil IV

›Indications

›Severe reactive airway disease

›Beta blocker intolerance

Adjunctive blood pressure and pain control

›Vasodilators after rate control only

›Nicardipine infusion

›Start 5 mg/hr IV

›Titrate by 2.5 mg/hr every 5 to 15 minutes to max 15 mg/hr

›Nitroprusside infusion

›Start 0.3 mcg/kg/min IV

›Titrate to max 10 mcg/kg/min

09Special Populations/sp45

Pregnancy

›Risk and physiology

›Highest risk third trimester and peripartum

›Hormonal aortic wall changes

›Hemodynamic and volume stress

›Associated aortopathy

›Marfan syndrome

›Bicuspid valve and coarctation

›Management adaptations

›Imaging

›CT angiography with abdominal shielding when needed

›MRI without gadolinium when stable

›Anti-impulse therapy

›Labetalol preferred

›Avoid nitroprusside near term due to fetal cyanide risk

›Delivery and surgery coordination

›Cesarean before repair if viable fetus

›Multidisciplinary obstetric and cardiac team

Geriatric

›Presentation differences

›Atypical features

›Syncope or altered mentation

›Less classic tearing pain

›Higher complication rate

›Greater baseline hypertension

›More extensive atherosclerosis

›Management considerations

›Surgical risk assessment

10Background/b44

Epidemiology

›Incidence and demographics

›Stanford Type A is 59 to 67 percent of acute aortic syndromes

›Defined by ascending aorta involvement

›Regardless of primary tear site

›Age and sex distribution

›Peak incidence 60 to 70 years

›Male sex about 65 to 70 percent

›Patients under 40 more likely genetic aortopathy

›Mortality burden

›Untreated course

›1 to 2 percent mortality per hour first 24 hours

›Medical management mortality about 57 percent

›Surgical outcomes

›Surgical mortality decreased from 25 to about 18 percent

›Best outcomes at high-volume centers

Pathophysiology

›Mechanism of dissection

›Intimal tear and false lumen

›Blood enters medial layer

›Propagation antegrade or retrograde

›Medial degeneration substrate

›Connective tissue gene defects

›Chronic hypertensive wall stress

›Complication pathways

›Proximal extension

›Coronary ostial occlusion causing MI

›Aortic root dilation causing acute AR

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Postoperative and long-term home care

›Take all blood pressure medications exactly as prescribed

›Keep blood pressure low as directed by your team

›Attend all surveillance imaging appointments for life

›Avoid heavy lifting straining and intense isometric exercise

›Lifestyle and prevention

›Stop smoking and avoid cocaine or stimulants

›Limit caffeine and follow a heart-healthy low-salt diet

›Ask family members about screening if a genetic cause was found

›Return to ER immediately for red flags

›Sudden severe chest back or abdominal pain

›New weakness numbness vision change or trouble speaking

›Fainting or near fainting

›Cool painful or discolored arm or leg

›Shortness of breath or very fast heartbeat

›Follow-up

›Keep cardiothoracic surgery follow-up appointments

›Keep cardiology and blood pressure follow-up appointments

›Bring an updated medication list to every visit

12References/r14

Guidelines and key sources

›Major guidelines

›2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease

›2024 EACTS/STS Guidelines for Acute and Chronic Aortic Syndromes

›2010 ACCF/AHA Thoracic Aortic Disease Guidelines

›2021 AHA/ACC Chest Pain Evaluation Guideline

›Landmark reviews and studies

›Carrel et al Acute Aortic Dissection Lancet 2023

›Nienaber and Clough Management of Acute Aortic Dissection Lancet 2015

›Mussa et al Acute Aortic Dissection and Intramural Hematoma JAMA 2016

›Ren et al ADD-RS diagnostic accuracy meta-analysis PLoS One 2023

›Coding standards

›ICD-10 I71.00 dissection of aorta unspecified site

›ICD-10 I71.01 dissection of thoracic aorta

›SNOMED CT aortic dissection disorder concept

Evidence & Review

Evidence & Review