Ep. 23 - Aortendissektion

the aorta will %$#@!& you up

Hallo zusammen

Diese Weekend etwas zur Aorta, genauer gesagt zur Aortendissektion. Zu diesem Thema gibt es in der FOAM-Welt auch eine Tonne an Einträge und Infos. Folgende Seiten kann ich euch sehr empfehlen:

Von SmaccDUB 2016

https://smacc.net.au/2017/04/aorta-will-uo/

Exzellenter Podcast (25min) von David Carr mit dazugehörigen Slides.

EMCrit hat auch einen super Podcast mit Fokus auf die Behandlung: https://emcrit.org/emcrit/aortic-dissection/

Grobzusammen gefasst:

1. Analgesie um Sympathikus zu plätten

2. Herzfrequenz senken (Esmolol, (Labetalol)) auf ca 60/min um Wandstress zu minimieren und

3. Blutdruck senken mit Ziel um ca 100-110mmHg

Lg norbert

Der Inhalt des Podcasts von Carr ist plusminus auf folgender Seite in Worte gefasst: https://emergencymedicinecases.com/aortic-dissection-em-cases-course/

Und zwar:

A) The Five Pain Pearls of Aortic Dissection

Pain Pearl #1: Ask the following 3 questions for all patients with torso pain:

• Quality of pain (most commonly “sharp” but highest LR for “tearing”)

• Pain intensity at onset

• Radiation of pain (back and/or belly)

A 1998 study that reviewed a series of aortic dissection cases showed that for the 42% of physicians who asked these 3 questions, the diagnosis was suspected in 91%. When less than 3 questions were asked dissection was suspected in only 49%. Pain Pearl #2: Think of aortic dissection as the subarachnoid hemorrhage of the torso

Just as the patient who presents with headache and is suspected of suffering from a subarachnoid hemorrhage, if the patient describes truly abrupt onset of severe torso pain with maximal intensity at onset, think aortic dissection.

Pain Pearl #3: Severe colicky chest pain + opioids = heightened suspicion

If you find yourself treating your chest pain patient with IV opioids to control their severe colicky pain, think about the possibility of aortic dissection.

Pain Pearl #4: Migrating pain has a +LR = 7.6

In addition to the old adage “pain above and below the diaphragm should heighten your suspicion for aortic dissection”, severe pain that progresses and moves in the same vector as the aorta, increases the likelihood of aortic dissection.

Pain Pearl #5: The pain can be intermittent as dissection of the aortic intima stops and starts

The combination of severe migrating and intermittent pain should raise the suspicion for aortic dissection.

Painless Aortic Dissection

While IRAD reported a painless aortic dissection rate of about 5%, a more recent study out of Japan reported that 17% of aortic dissection patients had no pain. These patients presented more frequently with a persistent disturbance of consciousness, syncope or a focal neurologic deficit. Cardiac tamponade was more frequent in the painless group as well.

B) The Concept of CP (chest pain) +1 and 1+ CP in Aortic Dissection

Big red devascularizes

The intimal tear in the aorta can devascularize any organ from head to toe including the brain, heart and kidneys, and so 5% of dissections present as strokes, ****and these certainly are not the kind of stroke patients who should be receiving tPA! An objective focal neurologic deficit in the setting of acute unexplained chest pain has +LR = 33 for aortic dissection. Some of the CP +1 phenomena to think about include:

—CP + CVA

—CP + paralysis

—CP + hoarseness (recurrent laryngeal nerve)

—CP + limb ischemia

In addition to thinking of CP +1 it may help to think backwards in time and ask the patient who presents with end organ damage if they had torso pain prior to their end organ damage symptoms. For example, for patients who present with stroke symptoms, ask them if they had chest pain, back pain or abdominal pain before the stroke symptoms.

C) Physical Exam Pearls in Aortic Dissection: Look, Listen & Feel

Anyone under the age of 40 years who presents to the ED with unexplained torso pain should be asked if they have Marphan’s Syndrome. In the IRAD under 40 years of age subgroup analysis, 50% of the aortic dissection patients had Marfan’s representing 5% of all dissections.

Look. The patient doesn’t always know they have Marphan’s so you need to look for the signs:

1. Arachnodactyly (Elongated fingers): if they look long try to elicit the wrist sign (see this 15 second video here)

2. Pectus excavatum : sternal excavation (see image)

3. Lanky limbs

Listen. A new aortic regurgitation murmur has a surprisingly high +LR = 5.

Feel. Feel for a pulse deficit which has a +LR = 2.7.

BP Pitfall: Do not assume that the patient with a normal or low BP does not have an aortic dissection. We know from the IRAD data that only about half of patients are hypertensive at initial presentation. Dissection that progress into the pericardium and end up with tamponade are often hypotensive.

BP Pearl: Patients with dissection who have a wide pulse pressure should be considered pre-terminal, and usually require immediate surgery.

What about bilateral BP differences in aortic dissection?

It’s important to know that 19 % of the general population have a BP difference between arms > 20 and 53 % > 10. This is important to take into account when coming up with a pretest probability.