AORTIC ANEURYSMS, DISSECTIONS, AND RUPTURES An Emergency Perspective

GOALS

•  Review Anatomy of the Aorta

•  Review Aneurysms, Dissections and Ruptures

•  Discuss Differing Presentations in the Emergency Patient

•  Emphasize the importance of our Assessment and History

ANATOMY REVIEW OF THE AORTA

4 parts of the Aorta More Details…

Artery Anatomy Thoracic vs Abdominal

CLASSIFICATIONS OF DISSECTIONS

Debakey Stanford

RISK FACTORS

•  **Hypertension

•  **Smoking

•  Atherosclerosis

•  Hyperlipidemia

•  Family History AAA

•  Stimulant use (cocaine)

•  Arteritis

•  Syphilis, TB

•  Pregnancy

•  Trauma - deceleration injuries

•  Cardiac- surgeries/catheterizations

•  Genetic disorders i.e. Marfan’s syndrome, Ehlers Danlos Syndrome and other connective tissue disorders

•  Male

•  African descent

DIAGNOSIS

•  Presentation/symptoms depend on location of the rupture or dissection

•  Mimics other conditions

•  Delays of diagnosis is the MOST common problem with these patient in the Emergency Department

CLASSIC TRIAD OF SYMPTOMS

•  Tearing/Ripping Abdominal or Chest Pain through to back

•  Hypotension

•  Pulsatile Abdominal Mass

*****These are present in only 25-50% of patients*****

COMMON PRESENTATIONS

•  Renal Colic

•  MI or Acute Coronary Syndrome

•  Congestive Heart Failure

•  Pulmonary Embolus/Pneumonia

•  Stroke / Neurological Symptoms

•  Right Pleural Effusion

•  Cholecystitis, Diverticulitis/GI pain

•  Musculoskeletal pain

DIAGNOSTICS

•  Based on the patient presentation.

•  Some research has indicated an elevated D-Dimer of greater than 500µg/dl can be indicative of aortic dissection.

•  CT scans: preferred exam with 90% accuracy .

•  Chest Xray: 50% patients with cardiac/respiratory symptoms will show mediastinal widening with dissections. ** important that this is done before giving thrombolytcs.

•  TEE: Useful with hemodynamically unstable patients. Sensitivity is 100% with high dissections- Type A. Disadvantage is must be done by someone with the skill.

•  Ultrasound: done at the bedside in ER, will show blood in the abdomen if the aneurysm has ruptured.

•  MRI: more sensitive than CT but impractical as is more time consuming and patient is inaccessible.

REPAIR OF DISSECTIONS/RUPTURES

•  Elective: may be open or endovascular (EVAR) •  Stanford A: usually at 5cm or greater Stanford B: usually at 6 cm or greater •  Medical management prior to surgery is aimed at decreasing the BP and

lowering the heart rate. Target BP in ER should be 100-120 systolic BP with heart rate around 60bpm

•  Pain should be controlled with opioids which also decrease the sympathetic tone.

•  *Early & Aggressive hemodynamic stabilization gives the best chance for successful surgical intervention.

AORTIC ANEURYSM RUPTURES

•  Risk factors are the same as with aortic aneurysm dissections

•  Thoracic aneurysms are less common with 80% of ruptures occurring below the level of the renal arteries

•  Initial ER assessment/treatment focuses on hemodynamic stabilization as these patients are often profoundly HYPOTENSIVE.

RESUSCITATION

•  Focus is A,B, and C

•  At least 2 large bore IVs crystalloids and blood products

•  Operating Room ASAP!

•  It is recommended by the Vascular surgeons, that all other invasive procedures be done in the OR to limit the risk of raising the BP too much

•  In ER, our AIM should be to improve/maintain end-organ perfusion!

•  Keep in mind that fluid overloading may disrupt the clotting cascade or dislodge a clot with severe negative impact on the patient

REMEMBER

•  Suspect the worst in patients with risk factors for AAA and abdominal pain.

•  Perform serial assessments and evaluations of the patient’s condition.

•  Be cautious with our female patients, their symptoms tend to be vague, down played and they are often under diagnosed and under treated.

•  Acute Abdominal pain with altered vital signs needs to be CTAS 2 and ideally assessed by a physician within 15 minutes.

•  Hypotension and extreme Hypertension are OMINOUS signs

•  With our knowledge we need to have a high index of suspicion with symptomatic patients with the mentioned risk factors.

•  Up 50% of patients do not have the “classic” presentations.

PATIENT PRESENTATIONS

•  48 y M -altered mental status, seizure , rt neck pain, lf hemiparesis & ST depression. Vfib arrest. Unsuccessful resuscitation

•  COD: Rt Carotid Artery Dissection

•  62 y F abdominal pain, altered mental status, syncope,ST depression - changed to ST elevation. Vfib arrest. Unsuccessful resuscitation

•  COD: Aortic Dissection into coronary arteries & hemopericardium

•  48 y F headache & seizure. Vfib arrest. Never had any abdominal or chest pain.

•  COD: Aortic Dissection

•  63 y M-cardiac type chest pain to rural centre, cardiac workup including Nitro, & Lovenox. Transferred for CT to R/O PE. Diagnosed with AAA. BPs were

•  Rt 158/90 Lf 167/87, Surgical repair Type B aneurysm, spent 4 d in ICU with Labetalol/Nitroprusside. Discharged 10d post op with meds.

•  68 y M sudden onset Rt. flank & back pain. Triaged “3” Renal colic, WR for 1 hr., collapsed. He was mottled from the waist down with weak femoral pulses. CT was done & pt. went OR in under 45 minutes.

•  He was discharged home 12 days post-op. He was a smoker with HTN

•  29 y F -chest pain into neck, jaw and arm. Squeezing pain, no SOB or diaphoresis. Rt. BP108/74 Lf. 136/79 Initial CT to R/O PE - not diagnostic but augmented, revealed Ascending Aortic dissection. Surgery was done successfully and she did well. This pt was in our ER for 6 hrs. before definitive diagnosis.

•  32 y M CTAS 2 Chronic back pain 5-6 yrs worse for “few days”

•  XR ordered by Chiropractor and they were suspicious of AAA- pain was lower back to RLQ, down anterior of rt thigh –NO abdo pain. Family history of AAA, HTN(noncompliant with meds) & non-smoker

•  Elective repair was done.

•  32y M 26 hr. chest/epigastric & back pain with hematuria. GP suspected Renal colic. He had a lot of pain and BP230. Syncopal and seizure in WR. CT Head & Chest=Type A Dissection. BP was stabilized. Transport to Vascular center. Augmented CT- dissection down descending aorta(T5) to common iliacs and rt. Hemothorax.

•  Pre-op pulses on left & minimal on rt. •  Stat Thoracic EVAR successful but pt left

paraplegic (T6) from arterial ischemia •  Current litigation.

FINAL THOUGHTS

•  Our assessments and history taking are VITAL for timely diagnosis.

•  Have a HIGH INDEX OF SUSPICION with patients with risk factors especially with abdominal or chest pain

•  Remember that the location of the aneurysm rupture will dictate the type of symptoms they present with.

•  Timely diagnosis and maintenance of end organ perfusion are of the Utmost importance for our patients.

•  Pat Mercer-Deadman RN ENC(C)

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