gemc- acute aortic emergencies- for residents
DESCRIPTION
This is a lecture by Carol Choe from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.TRANSCRIPT
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Project: Ghana Emergency Medicine Collaborative
Document Title: Acute Aortic Emergencies
Author(s): Carol Choe (University of Michigan), MD 2012
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OBJECTIVES
Discuss different types and pathologies of aortic disease.
Determine treatment and management options for each state.
Evaluate need for surgical intervention.
Review prognosis and outcome.
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The Aorta
Largest artery in the body.Carries oxygen-rich blood away from the
heart.Elastic (especially ascending aorta).3 layers of tissue
� Thin inner layer: tunica intima� Thick middle layer: tunica media � Thin outer layer: tunica adventitia
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Common Causes of Aortic Disease
HypertensionAtherosclerosisBicuspid aortic valve (alters laminar flow)Cocaine or MDMA useConnective tissue disorders Infection (syphilis, TB, salmonella)Pregnancy Injury (iatrogenic and traumatic)
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Case Presentation
76 year old woman with a history of hypertension presents to the emergency department with a sense of abdominal fullness.
Symptoms have been persistent for several weeks.
X-rays have been unremarkable.BP 94/48, HR 125, RR 20, SaO2 96%
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Case Presentation
What is your differential diagnosis?
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Aortic Aneurysm
James Heilman, MD, Wikimedia Commons
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Aortic Aneurysm
Any abnormal dilation or out-pouching of the aorta, greater than 50% of normal diameter.
Size matters:� Thoracic > 6cm� Abdominal > 5.5cm� Infrarenal aorta > 3cm
2 different shapes:� Fusiform� Saccular
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Signs/Symptoms
HoarsenessDysphagia.Chest/back pain.Shortness of breath.Abdominal discomfort.Sense of fullness.** Often asymptomatic until rupture.**
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Physical Exam Findings
Murmur if involving a valve.
Tamponade
Abdominal bruit (non-specific).
Pulsatile abdominal mass.
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Imaging Studies
CXR
Trans-thoracic echocardiogram
Ultrasound (modality of choice)
CT (non-contrast)
CTA (pre-intervention)
MRI/MRA
Conventional aortography (rarely used)
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Author unknown, http://www.ncbi.nlm.nih.gov/pubmed/22644671
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Aortic Aneurysm
James Heilman, MD, Wikimedia Commons
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Aortic Aneurysm
Risk factors:� Smoking� Males: Females 3:1� Age� Hypertension� Hyperlipidemia� COPD� Family history
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Aortic Aneurysm
Management:� Mortality related to size.� Medical management of small aneurysms
measuring <4.0-5.5 cm.
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Aortic Aneurysm
Sakhalihasan, N et al, Abdominal aortic aneurysm. The Lancet. 2005;365(9470):1577–1589.
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National Institutes of Health, Wikimedia Commons
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Aortic Aneurysm
Management: � Surgical repair commonly performed if aorta
>5.5cm.No mortality benefit to earlier surgical
intervention.Mortality from surgical intervention varies
from 1.1-7%.
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Aortic Aneurysm
Risk of rupture:� If <5 cm, is <1% per year.� If 5 cm, is 3-5% per year.� If >5 cm, is as high as 5% per year.
For ascending aortic aneurysms, yearly risk of rupture, dissection, or death at 6 cm is 14.1%!
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Aortic Aneurysm
Open Surgical Intervention� Reported failure rate of 0.3%.
Endovascular repair� Preferred for elderly patients.� Reduced perioperative morbidity and
mortality� Possible failure rate of 3% with multiple
complications possible.
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Aortic Aneurysm
Risk factors for death from ruptured aortic aneurysm:� Age >76 years� Cr >190umol/L� Hgb <9 g/dL� LOC� EKG evidence of ischemia.
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Aortic Aneurysm
Mortality from ruptured aortic aneurysm:� 100% mortality if 3+ risk factors.� 48% 2 risk factors.� 28% 1 risk factor.� 18% with no risk factors.
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Aortic Aneurysm
Prevention:� Stop smoking!� β-blockers may reduce the extent of growth
for large >5.0cm aneurysms.� Statins may reduce mortality post-
operatively.
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Case Presentation
54 year old man presents with sudden onset of pain between his shoulder blades which started when he lifted his wife.
X-ray has been unremarkable.VITALS:
BP 201/169 HR 104 RR 24 SaO2 96%RA
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Case Presentation
What is your differential diagnosis?
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Aortic Dissection
Jheuser, Wikimedia Commons
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Aortic Dissection
Medial degeneration.
A tear in the tunica intima allows blood to dissect between the intima and media.
True incidence of the disease is unknown.
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Aortic Dissection
DeBakey Classification:� Type I: Ascending and descending aorta.� Type II: Ascending aorta only.� Type III: Descending aorta distal to the L.
subclavian. Stanford Classification:
� Type A: Involving the ascending aorta.� Type B: Involving the descending aorta distal to
the L. subclavian artery.
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Aortic Dissection
Type A dissection often begins just above the coronary arteries where the aorta is the largest and thinnest. � Always a surgical emergency.
Type B dissection involves the distal aorta. � Medically managed.
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Aortic Dissection
Jheuser, Wikimedia Commons
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Signs/Symptoms
Sudden onset of sharp, tearing pain radiating to the back.
Any neurologic complaints associated with pain.
Syncope.
Acute CHF.
Other vague non-specific symptoms.
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Physical Exam Findings
Hypoxia
Altered mental status
Tachycardia
Pulse deficits
BP discrepancies
Shock
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Aortic Dissection
However, landmark study (International Registry of Aortic Dissection) found:� pulse deficit: 15 %� aortic murmur: 31.6 %� normal chest x-ray: 12 %� absence of mediastinal widening: 34 %� syncope: 12 %� painless: 2.2%
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Imaging Studies
CXR
CT
MRI/MRA
TEE
TTE (low sensitivity: 55-75%)
Angiography (former “gold standard”)
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Imaging Studies
Classic teaching of CXR findings:� Widened aortic knob or mediastinum.� Displaced intimal calcification.� Pleural effusion (left >> right).� Opacification of the “AP window.” � Left apical pleural cap.� Indistinct or irregular aortic contour.� Tracheal or esophageal deviation.
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Aortic Dissection
James Heilman, MD, Wikimedia Commons
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I heard you can use the d-dimer…
The d-dimer is almost 100% sensitive for acute dissection. HOWEVER, specificity is low.
Useful in the high negative predictive valueA false positive d-dimer would require CT
scanning of approximately 40% of the patients
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Aortic Dissection
Mortality 1-2% per HOUR for type A dissections.� 75% within 2 weeks, 90% mortality at 30
days.With successful initial therapy:
� 5-year survival rate is 75%� 10-year survival rate (if surgically repaired)
is 40%-60%.
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Aortic Dissection
Treatment strategies are similar to aortic aneurysm:� Medical:
MorphineAnxiolyticsAfterload reduction and β-blockade
� Goal SBP 100-110mmHg� Goal HR 50-60bpm
� Surgical
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Aortic Dissection
Surgery is indicated for all type A dissections. Indicated for type B dissections only if :
� Persistent symptoms.� Rapidly expanding false lumen.� Impending or frank aortic rupture.� Major organ malperfusion that cannot be
resolved by percutaneous therapy.
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Aortic Dissection
Increased risk of death:� Older age.� Signs and symptoms of organ malperfusion.� Clinical instability (pulse deficits, renal
failure, hypotension, and/or shock).
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Aortic Dissection
Despite advances in medical/surgical treatment,� 15-30% of patients will require further
surgical intervention for complications:aortic dilatation and rupture (most
common cause of death)progressive aortic regurgitationorgan malperfusionirreversible ischemia
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Case Presentation
24 year old man, restrained driver involved in a high-speed MVC vs. tree.
Airbags deployed. Complaining of chest pain and
shortness of breathVITALS:
BP 98/52 HR 132 RR 26 SaO2 90% RA
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Case Presentation
What is your differential diagnosis?
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Signs/Symptoms
Inter-scapular painDyspneaDysphagiaRelative upper extremity hypertension
("pseudo-coarctation")** Often do not make it into the ED**
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Physical Exam Findings
Seat-belt or steering wheel imprint.
May find evidence of rib fractures.
Left supraclavicular hematoma.
New murmur.
In-hospital death between 50-100%, exsanguinating hemorrhage being the most important cause of early death.
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Imaging Studies
CXRSpiral CT (97-99.3% sens, 87.1-99.8% spec)CTAMRITEE Intravascular ultrasonographyBi-planar angiography
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Imaging Studies
Wellcome Images, Wellcome Images
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Blunt Aortic Injury
Most commonly thoracic, rarely abdominal.
Various gradations of injury:� Intimal tear.� Intramural hematoma.� Pseudoaneurysm.� Free rupture.
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Blunt Aortic Injury
James Heilman, MD, Wikimedia Commons
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Blunt Aortic Injury
Estimated 7,500 - 8,000 cases per year in the United States.
Blunt thoracic trauma is second most common cause of trauma-related death after head injury.
Thoracic aortic rupture accounts for nearly 18% of all deaths in motor vehicle collisions.
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Blunt Aortic Injury
For those who initially survive, the prognosis remains poor:� ~30% die within first 6 hours.� 50% will not live beyond the first 24 hours.
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TRAINS Score
Predictors of aortic injury include:� Widened mediastinum.� BP <90 mmHg.� Long bone fracture.� Pulmonary contusion.� Left scapula fracture.� Hemothorax.� Pelvic fracture.
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Blunt Aortic Injury
The isthmus is area of greatest strain.
Tensile strength at the isthmus was found to be only 63% of that of the proximal aorta.
Aortic ruptures occur at this site in 80% of the pathological series and in 90-95% of the clinical series.
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Blunt Aortic Injury
Rupture (descending order):� Isthmus� Ascending aorta� Aortic arch� Distal descending aorta� Abdominal aorta
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Blunt Aortic Injury
Theory on mechanism of blunt aortic injury:� shearing stress during rapid deceleration.� compression of the aorta between
sternum and thoracic spine (osseous pinch).
� direct load causing aortic wall strain and medial tears.
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Image removed of blunt aortic trauma
Blunt aortic injury. N. Engl. J. Med. 2008;359(16):1708–17 http://www.nejm.org/doi/full/10.1056/nejmra0706159
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Blunt Aortic Injury
Associated extra-thoracic injures are common, particularly abdominal and intracranial.
Morbidity (amputation and brachial plexus injury) is frequent.
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Treatment
Initially thought to be fatal (Parmley).Traditional treatment: early open surgical
repair with graft interposition. Hemodynamic instability upon
presentation remains the main mortality risk factor.
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Treatment
Small pseudoaneurysms and intimal injuries can generally be managed expectantly.
Delayed repair is safe in certain patient populations.
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Treatment
For hemodynamically stable patients, may start β-blockers to lower MAP and to decrease aortic shear force. � The target mean arterial pressure is
between 60 and 70 mmHg.HOWEVER, if there is a significant associated
cerebral injury, even mild hypotension may worsen the neurologic outcome and normal blood pressure should be maintained.
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Advantage of
Avoidance of:� thoracotomy� single-lung ventilation� aortic cross clamping� left heart or cardiopulmonary bypass.
Expeditious
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Disadvantage of
Endograft size tends to be largeStill uncertain complications
� Migration of graft� Erosion of graft
Unknown long-term outcomes
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Possible Complications
2 peaks for complications:� During the first week: those with major or
borderline aortic radiologic injury� Between the first and third months
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Diagnosis of Aortic Disease
Maintain a high level of suspicion!
No one test is perfect.
CT scan if possible, otherwise TTE/TEE if available.
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27. Anon. Volume 1/PART III/Section Four/Chapter ... from Rosen.