01Approach to the Critical Patient/attcp64

Immediate priorities

›Acute aortic syndrome recognition

›Abrupt severe chest, back, or abdominal pain

›Maximal at onset

›Tearing or ripping quality

›Type B specific pain pattern

›Back pain in 64% of cases

›Chest pain in 63% of cases

›Abdominal pain in 43% of cases

›Migratory pain as dissection propagates distally

›Distal extension clue

›Branch vessel involvement clue

›Complicated versus uncomplicated triage

›Complicated features reclassify and trigger urgent intervention

›Malperfusion syndrome

›Rupture or impending rupture

›Refractory pain or refractory hypertension

›Rapid aortic expansion on serial imaging

›Uncomplicated pattern supports medical management

›No malperfusion

›Pain and blood pressure responsive to therapy

›If any complicated feature, immediate vascular or cardiothoracic surgery activation

›TEVAR pathway preparation

›Class I recommendation for intervention

›Hemodynamic stabilization sequence

›Anti-impulse therapy first

›IV beta-blocker before vasodilator

›Reflex tachycardia prevention

02History/hx78

Presentation pattern

›Pain characteristics

›Onset

›Abrupt or instantaneous

›Maximal at onset

›Quality

›Sharp or stabbing

›Tearing or ripping

›Location and migration

›Interscapular back pain

›Migration as dissection propagates

›Temporal classification

›Hyperacute under 24 hours

›Highest early risk window

›Acute management focus

›Acute 1 to 14 days

›Standard acute pathway

›Serial imaging window

›Subacute 15 to 90 days

›Continued surveillance

›Intervention reassessment

›Chronic over 90 days

›Aneurysmal degeneration risk

›Long-term blood pressure control

Malperfusion symptoms

›Symptom review for malperfusion

›Limb ischemia

›Leg pain

03Physical Exam/exam45

Vital signs and perfusion

›Blood pressure assessment

›Hypertension common at presentation

›Anti-impulse therapy indication

›Wall stress driver

›Bilateral arm pressures

›Asymmetry over 20 mmHg suggests branch compromise

›Document baseline for titration

›Hypotension as red flag

›Rupture concern

›Tamponade concern

›Pulse examination

›Four-extremity pulses

›Pulse deficit localization

›Asymmetry trend

›Limb perfusion

›Cool or mottled limb

›Pulseless extremity

Cardiac and vascular exam

›Cardiac findings

›New diastolic murmur

›Aortic regurgitation

›Retrograde extension clue

›Signs of tamponade

›Muffled heart sounds

›Elevated jugular venous pressure

›Abdominal and vascular findings

›Abdominal tenderness

04Differential Diagnosis/ddx33

Life-threatening diagnoses

›Immediate threats

›Acute coronary syndrome

›ICD-10 I21.9

›Most common misdiagnosis

›Pulmonary embolism

›ICD-10 I26.99

›D-dimer elevated in both entities

›Tension pneumothorax

›Unilateral breath sounds

›Tracheal deviation

›Esophageal rupture

›Post-emesis onset

›Subcutaneous emphysema

Acute aortic syndrome spectrum

›Aortic syndrome variants

›Aortic dissection Stanford type B

›ICD-10 I71.01

›Descending aorta distal to left subclavian

›Intramural hematoma

›Non-contrast crescentic wall thickening

›No intimal flap

›Penetrating aortic ulcer

›Atherosclerotic substrate

›Focal contrast outpouching

Mimics by presentation

›Differentiating clues

›Pericarditis or myocarditis

05Laboratory Tests/lt42

Diagnostic and rule-out labs

›D-dimer

›Sensitivity about 94% for acute dissection

›Negative under 500 ng/mL with low risk effectively rules out

›Combine with risk score for safe exclusion

›Markedly elevated values

›Over 1600 ng/mL strongly suggest acute aortic syndrome

›Higher false lumen burden association

›Troponin

›Usually normal in type B

›Positivity does not rule out dissection

›Coronary malperfusion or demand ischemia if elevated

›Alerting triad

›Normal ECG

›Normal troponin

›Elevated D-dimer

Malperfusion and perfusion labs

›Perfusion markers

›Lactate

›Elevation suggests malperfusion

›Metabolic acidosis correlate

›Creatinine and BMP

›Renal malperfusion

›Contrast planning input

›LFTs and lipase

›Mesenteric malperfusion screen

›Hepatic or pancreatic ischemia

›Urinalysis

06Diagnostic Tests/dt74

Scoring Systems

›Aortic Dissection Detection Risk Score

›Three high-risk categories

›Predisposing conditions

›Pain features

›Examination findings

›Interpretation thresholds

›Score 0 to 1 lower probability

›Score 2 to 3 higher probability

›Combined exclusion pathway

›ADD-RS 1 or less with D-dimer under 500 ng/mL

›Sensitivity up to 98 to 99% for ruling out acute aortic syndrome

›Severity and high-risk morphology

›Uncomplicated criteria

›No malperfusion or rupture

›Pain and blood pressure controlled

›High-risk anatomic features

›Aortic diameter over 40 to 44 mm

›False lumen diameter over 22 mm

›Entry tear over 10 mm

›Entry tear within 20 mm of left subclavian artery

MRI

›MRI angiography role

›Strengths

›High accuracy for flap and extent

›No ionizing radiation

›Limitations

›Long acquisition time

07Disposition/dispo31

Level of care

›ICU admission

›All acute type B dissections

›Hemodynamic monitoring

›Serial neurovascular exams

›Anti-impulse titration

›Arterial line monitoring

›Pain control

›Surgical and interventional triggers

›Complicated features

›Malperfusion

›Rupture or impending rupture

›High-risk morphology on CTA

›Prophylactic TEVAR discussion

›Multidisciplinary review

Transfer and discharge

›Transfer criteria

›No on-site aortic intervention capability

›Early transfer to aortic center

›Continued anti-impulse therapy in transit

›Complicated dissection

›Time-critical TEVAR access

›Vascular surgery acceptance

›Discharge criteria after stabilization

›Pain controlled on oral medications

›No refractory pain

›Stable analgesia plan

›Blood pressure at goal on oral regimen

08Treatment/t74

Acute anti-impulse therapy

›IV beta-blockade first line

›Esmolol infusion

›500 mcg/kg IV bolus over 1 minute

›50 mcg/kg/min continuous infusion

›Titrate 25 to 50 mcg/kg/min every 5 to 15 minutes to target

›Maximum 300 mcg/kg/min

›Labetalol alternative

›20 mg IV bolus

›Repeat 20 to 80 mg every 10 minutes

›Infusion 0.5 to 2 mg/min

›Cumulative maximum 300 mg

›Hemodynamic targets

›Heart rate 60 to 80 beats per minute

›Systolic blood pressure 100 to 120 mmHg

›Class I recommendation for IV beta-blockade

›Add-on vasodilator after beta-blockade

›Nicardipine infusion

›Start 5 mg/hr IV

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

›Maximum 15 mg/hr

›Only after adequate beta-blockade

›Nitroprusside alternative

›Start 0.3 mcg/kg/min IV

›Titrate to blood pressure target

›Maximum 10 mcg/kg/min

›Avoid without prior beta-blockade due to reflex tachycardia

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Risk timing

›Type B more common postpartum

›Third trimester hemodynamic stress

›Connective tissue overlap

›Marfan syndrome risk

›Aortic root surveillance

›Medication safety

›Labetalol preferred

›Avoid ACE inhibitors and ARBs

›Imaging approach

›MRI without contrast preferred

›CT with shielding when benefit outweighs risk

Geriatric

›Older adult features

›Atypical presentation

›Less classic tearing pain

›Syncope or altered mentation

›Comorbidity burden

›Chronic kidney disease affecting contrast

›Polypharmacy interactions

›Medication titration

›Cautious beta-blocker dosing

›Fall and hypotension risk

›Procedural considerations

›TEVAR often favored over open repair

›Frailty assessment

10Background/b58

Epidemiology

›Disease burden

›Demographics

›Mean age about 63 years

›Male predominance

›Progression risk

›25 to 40% of uncomplicated cases progress to complicated disease

›Aneurysmal degeneration exceeds 70% at 3 to 5 years

›Mortality

›Uncomplicated in-hospital mortality 1 to 10%

›Complicated early mortality about 16%

›Follow-up adherence burden

›Loss to follow-up

›About 50% lost by 28 months

›Surveillance adherence critical

›Late complications

›38% of medically managed patients develop complications requiring intervention

›Late aortic events

Pathophysiology

›Mechanism of dissection

›Intimal tear

›Distal to left subclavian artery

›Blood enters media

›True and false lumen formation

›Intimal flap

›False lumen propagation

›Wall stress drivers

›Hypertension

11Patient Discharge Instructions/pdi20

copy discharge instructions

›Aortic dissection home care

›Take all blood pressure medications exactly as prescribed

›Keep blood pressure at or below 120/80 if monitoring at home

›Do not stop beta-blocker suddenly

›Stop smoking and avoid cocaine or stimulants

›Activity guidance

›Avoid heavy lifting and straining

›Avoid collision and contact sports

›Light to moderate walking is encouraged

›No Valsalva or breath-holding during exertion

›Warning signs to return to ER

›New or worsening chest, back, or abdominal pain

›Leg pain, weakness, or color change

›Decreased urine output

›Fainting or near-fainting

›Any new numbness, weakness, or trouble speaking

›Follow-up

›Repeat CT or MRI at 1 month, 6 months, and 12 months

›Vascular or cardiothoracic surgery clinic appointment

›Primary care for blood pressure monitoring

12References/r12

Guidelines and key sources

›Society guidelines

›2022 ACC/AHA guideline for diagnosis and management of aortic disease

›STS/AATS clinical practice guidelines on type B aortic dissection

›EACTS/STS guidelines for acute and chronic aortic syndromes

›Landmark evidence and reviews

›INSTEAD-XL trial on TEVAR plus medical therapy

›NEJM 2025 review on management of acute type B aortic dissection

›JACC review on optimal treatment of uncomplicated type B dissection

›Decision tools and coding

›Aortic Dissection Detection Risk Score with D-dimer meta-analysis

›ICD-10 I71.01 dissection of thoracic aorta

›2021 AHA/ACC chest pain evaluation guideline

Evidence & Review

Evidence & Review