Aortic Emergencies:True Jeopardy

Meira LouisDr Adam Oster

Ouch, my back! Fat Pipes In real life... Aortic Pics

10 10 10 1020 20 20 2030 30 30 3040 40 40 40

Ouch, my Back! 10 pts

What are type A and type B dissections and what

percentage of dissections account for each?

62% 38%

Name five indications for a surgical approach

Ouch, my Back! 20 pts

When Surgery?

• All Type A

• Type B if:– Persistent pain– Uncontrollable hypertension– Occlusion of a major artery or branch point– Frank leak or rupture– Development of an anurysm

Surgical mortality: 27%Medical mortality: 56%

Surgical mortality: 32%Medical mortality: 10%

Type A repair

Ouch, my Back! 30 pts

What is pseudohypotension

When the intimal flap obstructs the flow to one or more limbs, giving low blood pressure peripherally, but adequate central pressure

Signs and Symptoms• Blood Pressure

– Type A 36%, Type B 70%• Sudden severe sharp chest pain - 73%

– Type A – anterior pain– Type B – back or abdominal pain

• Syncope – 13% of Type A• Abdominal pain

– Type A 22%, Type B 43%• Aortic insufficiency murmur

– Type A 44%, Type B 12%• Pulse Deficits – less than 30%

Demographics• Under 40

– More likely to present without HTN– More likely to have a bicuspid aortic valve or have

had prior aortic valve surgery

Peak time of day - 8-9amPeak time of year – Winter (October-January)

Mehta et al. IRAD investigators. Circulation. 2002; 106(9):1110-1115.

Ouch, my Back! 40 pts

What two parameters are you targeting with medical

management, and what two drugs would you use to help

get you there?

Goal One: dP/dT

• Beta blockers to get your heart rate under 60– Esmolol

• 5g in 500ml of D5W• Bolus 500µg/kg, then infuse

– Labetolol• 20mg IV bolus q5-10 minutes• Then infuse at 1-2µg/min

– If history of bronchospasm/COPD can use β only (metoprolol)

Goal Two: Blood Pressure

• Want to reduce the afterload– Sodium Nitroprusside

• Dont use:– Nifedipine

• Can increase shear stress on wall– Nitroglycerine

• Less effective than nitroprusside

Long Term

Fat Pipes 10 points

At what size does a thoracic aortic aneurysm greatly increase its likelihood of

rupture?

Rates and Measurement

Hinge Points

AAA

Fat Pipes 20 points

DAILY DOUBLE

What is the name of this condition and what causes it?

Blue Toe Syndrome

• Microemboli of cholesterol crystals or clot• Palpable pedal pulses and cool, cyanotic toe

Palpable Mass

Size Felt on exam

3.0-3.9cm 30-60%

4.0-4.9cm 50-70%

>5cm 75-85%

Fat Pipes 30 points

What is the sensitivity of ED ultrasound for detecting abdominal aortic aneurysms?

Overall:• 73 studies reviewed• 4 studies included• All used convenience samples of symptomatic patients• Sensitivity 94-100%• Specificity: 98-100%• No differences by level of training

Fat Pipes 40 points

For an asymptomatic patient with AAA of 4.2cm, does the

evidence support any interventions, other than

imaging follow up?

Smoking cessation is recommended.

Level of recommendation: Strong

Quality of evidence: High

Statins may be considered.Level of recommendation: Weak

Quality of evidence: Low

Doxycycline, roxithromycin, ACE inhibitors, and angiotensin receptor blockers are of uncertain benefit.

Level of recommendation: Weak

Quality of evidence: Low

The use of beta blockers is not recommended.

Level of recommendation: Strong

Quality of evidence: Moderate

Screening for AAA is recommended for first degree relatives of patients with an AAA.Level of recommendation: Strong

Quality of evidence: High

Evolving Research

• Statins – Schouten et al, 2006• ACE inhibitors – Hackam et al, 2006• ARBs – Mochizuki et al, 2007• Antibiotic agents - Mosorin et al, 2001

In real life... 10 points

• 76yo female with 45 minutes of pain radiating to the back

• Chronic HTN, dyslipidemia, osteoarthritis• BP 161/95, HR 117• Bedside U/S is suspicious for a ruptured AAA

What ED management would you undertake?

Ruptured AAA management

• Two large bore IVs• Crossmatched blood (massive transfusion)• BP management

– Permissive hypotension– Need to prevent end-organ damage

• MI, resp failure, renal failure in post-op period– NO evidence that lowering HTN helps

• Surgery

In real life... 20 points• A 72 yo male presented with acute onset of

bilateral lower limb ischemia• Creatinine was elevated at 340• Hb was stable at 154, no evidence of a GI

bleed

Aortocaval Fistula

•Abdominal or back pain•Continuous abdo. bruit (75%)•Palpable abdominal thrill (25%)•High Output CHF signs

• Dyspnea• Jugular venous distension• Pulmonary edema

Aortocaval Fistula

• Dilated superficial veins on legs and abdominal wall• Venous rupture in GI and bladder

• Gross hematuria• Rectal bleeding

• Renal insufficiency

In real life... 30 points

• 43 yo male with history of alcohol abuse• Bright red emesis and melena•BP 80/20, HR 120/min•No meds, no surgical hx, no prior GI bleeds•Normal INR/PTT, platelets•Endoscopy showed clots, but no source of bleeding

Aorto-enteric Fistula

• Third or Fourth segment of the duodenum• Primary vs Secondary• First stage

– Leaking GI contents, abscess• Second Stage

– Erosion of vessels in bowel wall• Third Stage

– Rupture into GI lumen

In real life... 40 points• 72yo male presents with vague , dull

abdominal pain• Intermittent abdominal bruit can be heard• BP 115/85, HR 72 • Underwent successful Dacron endovascular

AAA repair 1 month ago• History of controlled HTN, diabetes, CAD

What must be ruled out?

Endoleaks

Aortic Pics 10 points

Who is this man and what did he die from?

John Ritter

• Collapsed on set in 2003 and died the same day

• Widow sued his radiologist and cardiologist– "Both sides agree that his true condition -- an

aortic dissection, which is a tear in the largest blood vessel in the body -- was not identified until right before his death.“

Aortic Pics 20 pts

Name the following sign:

-widening aortic knob- widening of mediastinum- widening of descending aorta- widening of ascending aorta- parasternal shadow widening

-pleural effusion- tracheal shift

-blurring of aortic knob- localising lump on aortic arch distal to great vessels

-displacement of intimal calcification >6 mm

Chest Film

CT

Other Modalities

• TTE• TEE• MRI

Aortic Pics 30 points

On the morning of 25 October 1760, this man entered his

water closet and, after a few minutes, his valet heard a

loud crash. The valet entered the water closet to find him on the floor. He was lifted

into his bed, and asked for his daughter, but before she

reached him, he was dead.

A) William IIIB) George IIC) Adam I

D) Henry VI

King George II of England

Died of a Thoracic Aortic Dissection

DAILY DOUBLE

Aortic Pics 40 points

• A 69-year-old white male scientist consulted his physician because of pain in the upper abdomen. For a number of years he had suffered from attacks of upper abdominal pain, which usually lasted for 2-3 days and were often accompanied by vomiting. These attacks usually occurred about every 3 or 4 months.

• The patient was a pipe smoker and slightly overweight. The rest of his history was noncontributory. On physical examination, his physician noted a pulsating mass deep in the center of the abdomen.

Which famous scientist died of a ruptured aortic aneurysm?

Albert Einstein

• Exploratory laparotomy in 1948 showed a “grapefruit sized” mass• Experimental surgery by Dr R. Nissen•Polythene cellophane

• Died five years later of rupture