aortic dissection- morning report
Post on 22-Nov-2014
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Morning Report
Diana GirnitaMD, PhD
94 yo White female admitted in the ER
CC: Shortness of breath
What would you like to know?
•Dyspnea initially with exertion, then at rest over a 24h period
•Cough with white mucus•Recently, admitted for 2 weeks at TCH •3 days after d/c presented back to TCH
with SOB
ROS• CONSTITUTIONAL: Subjective fevers, no chills. Weight
gain > 10 lbs over her baseline weight of 103 pounds. Weakness
• EYES: no photophobia or discharge • ENT: no sore throat or ear pain. Reduced hearing• CARDIOVASCULAR: knife type of CP for seconds, no
palpitations• GI: no abdominal pain, N/V/ some diarrhea for 2 days -
resolved. • MUSCULOSKELETAL: no back pain/ muscle pain • SKIN: No rash • NEUROLOGIC: No HA, focal weakness or sensory changes • ENDOCRINE: No polyuria or polydypsia • PSYCHIATRIC: no depression, suicidal ideation or
homicial ideation
PMH• HTN. Hyperlipidemia . CHF• Arthritis • Breast cancer s/p Left masectomy with
lymph node removal• Urinary Incontinence• GERD • Hearing loss• Asthma • Cataract • Anxiety
Meds•Amlodipine 10mg/ day•ASA 81 mg/day•Hydralazine 10mg Q8H•Lisinopril 20 mg BID•Metoprolol 25mg BID•Nitro 0.2mg/hr patch•Furosemide 40mg/day•Pantoprazole 40mg po•Lipitor 40mg/day•Ergocalcipherol Q7days
FH and Social
•FH not significant•Social: not a smoker, no EtOH, no ilicit
drugs, retired, former dancer
VS
At admission in the ER:•SaO2 at RA 87% •ABG 7.47/30/50/21.5;•started on 4L/min O2 on NC
•BP 107/58 | Pulse 83 | Temp(Src) 97.3 °F (36.3 °C) (Oral) | Resp 31 | SaO2 91% |
Physical exam• General: well developed, well nourished • HEENT: PERRLA, EOMI, throat non-edematous or
erythematous, mucous membranes moist • Neck: normal ROM, nontender, trachea midline,
lymph nodes non palpable , no JVD, no carotid bruit • CV: RRR, distant S1, S2, no m/r/g w/o PMI.• Resp: dullness about one third up, with diminished
BS bilaterally, without rales • Abd: soft, slightly distended, positive normoactive
BS, nontender • Ext: 2+ pulses, 1+ pitting edema • Skin: warm, dry, and intact, no rash • Neuro: alert and oriented x 3, CN II-XII grossly
intact, motor and sensory function intact with no focal deficits
Differential diagnosis
Pulmonary vs cardiac causes▫ Upper airway obstruction:
trauma, laryngeal edema, laryngospasm, aspiration of foreign body, epiglotitis, croup
▫ Lower airway obstruction: asthma, COPD, neoplasm
▫ Pulmonary infection: PNA, empyema, absscess, TB, bronchiectasis
▫ PE▫ Pulmonary HTN▫ PNTx▫ Pleural effusions▫ Interstitial lung dx: sarcoidosis,
collagen vascular disease, pulmonary fibrosis
▫ Pneumoconiosis: silicosis▫ mesothelioma
• MI• Valvular lesions• Arrythmias• CHF decompensation• Pericardial effusion/cardiac
tamponade • CMP• Ao dissection• CAD• Cardiac shunts
Other causes• Musculoskeletal: broken
ribs, severe kypho scoliosis, sternal compression, morbid obesity
• Gastrointestinal (large hiatal hernia)
• Neurologic disease: GBS, polio, botulism, spinal cord injury
• Thyreotoxicosis • Uremia, DKA, hepatic
coma
• Anemia –acute blood loss• Polycythemia • Diaphragmatic
compression caused by abdominal distension /ascitis
• Sepsis• Diaphragmatic paralysis• Anxiety
Labs
•CBC•BMP•Cardiac enzymes•D-dimers•Liver profile•BNP•LA
ECG 12/19/11 – did not differ from previous admission
Previous admission- Type A aortic aneurism with dissection and intramural hematoma 2 weeks ago•CC: substernal pain for about 2 days•Coded due to PEA• 2min CPR done, pulse regained •Complications of CPR: 2-6 broken ribs•D/c stable on medical management of
HTN to a SNF
Previous CT 12/02/2011• R 2-6th, and possibly the 7th rib fractures
• CT Chest:▫ Mildly increased size of the ascending thoracic aorta aneurysm
with type A dissection 5.6 x 5.1 cm (previously 5.2 x 4.8 cm on 11/28/2011).
▫ Increased size of ascending aorta intramural hematoma▫ Increased size of pericardial effusion with with component of
hemopericardium▫ Increased moderate pleural effusions with simple fluid increased
bilateral lower lobe passive atelectasis▫ Stable mild fusiform dilation of proximal descending thoracic aorta
measuring 2.8 cm
• CT Abdomen:
No abdominal aorta aneurysm or dissection
Previous ECHO 12/02/2011• LV: The cavity size was normal. Wall
thickness was normal. Systolic function was normal. The estimated EF-60 to 65%.
• Pericardium - moderate to large, echogenic circumferential pericardium with small echo-free visceral and parietal pericardial spaces, suggestive of possible effusive or hemorrhagic pericarditis.
• Pericardial tissue grossly thickened without significant intra-pericardial fluid.
What to order next?
CXRV/Q scan CTPA
CXR 12/19/11
•Significant reduction in bilateral effusions and lower lung airspace disease since previous exam
V/Q scan 12/19/11
•Intermediate probability pattern for pulmonary embolus
What is the next step?
ECHO CT chestLEs venous doppler
ECHO revealed cardiac tamponade• LV cavity size was normal. Wall thickness -normal. Systolic
function was normal. The estimated EF = 65%. Wall motion was normal; there were no regional wall motion abnormalities. Dopplerconsistent with abnormal LV relaxation (grade 1 diastolic dysfunction). Aortic valve:Trivial regurgitation
• Pericardium: A large free-flowing pericardial effusion was identified circumferential to the heart. The fluid exhibited afibrinous appearance.
• There was RV chamber collapse for less than 50% of the cardiac cycle.
• There was evidence for increased RV-LV interaction demonstrated by respirophasic changes in tricuspid velocities. Featureswere consistent with tamponade physiology.
LEs venous doppler 12/20/11
•acute, isolated, occlusive deep venous thrombosis involving the bilateral soleal veins in the mid calves.
•no evidence of superficial venous thrombosis in the bilateral lower extremities.
• no evidence of significant venous valvular incompetence in the deep or superficial veins of the bilateral lower extremities
Consults
•Cardiology•Thoracic surgery•Palliative care
Problem list
1.Hypoxic respiratory failure▫Cardiac tamponade 2/2 Ao dissection▫PE 2/2 LEs DVTs▫Rib fractures
2.AKI
3. Anemia. Thrombocitosis
4.Abnormals LFTs/ passive congestion liver
Plan
•IVC Filter•No pericardial drainage•US guided thoracocentesis (removed 600
ml blood tinged fluid on the L side)•IVF at 50ml/hr, then Lasix iv ---po•Xopenex Q6H•Metoprolol 25mg BID, stopped all other
hypertensive meds
Repeat CT chest after fluid removal•Type A aortic dissection with dilatation of
the ascending aorta to 5.6 cm, unchanged. Intramural hematoma is unchanged.
•Large complex pericardial effusion, increased from 12/10/2011.
• Moderate bilateral pleural effusions, worse on the right, similar to 2/10/2011
Aortic Dissection
Definition• tear in the aortic intima, blood passes into the aortic
media through the tear, separating the intima from the surrounding media and/or adventitia, and creating a false lumen
Common presenting group
▫>50 yo with HTN▫2/3 male▫Marfan’s syndrome▫Congenital heart disease▫Pregnancy
Clinical features▫>85% abrupt onset, severe pain in chest or b/w
scapula, described as “ripping or tearing”▫Pain in anterior chest –ascending aorta (70%)▫Back pain (less common) –descending aorta
(63%)▫If dissection into carotid classic neuro
symptoms▫40% with neurologic sequelae (ex. paraplegia)▫Most have sense of impending doom!
Classification
•Stanford Classification▫Type A -involves ascending aorta▫Type B –involves descending aorta
•DeBakey Classification▫Type I –ascending, arch & descending
aorta▫Type II –ascending only▫Type III –descending only
Physical Exam▫Usually normal heart and lung exam▫May have aortic insufficiency▫<20% with decreased radial, femoral or
carotid pulse▫HTN/ hypotension▫Tachycardia
Physical Exam▫Pericardial tamponade (muffled heart
tones, JVD, pulsus paradoxus)▫Hoarseness (compression of recurrent
laryngeal nerve)▫Horner’s Syndrome (compression of
superior cervical sympathetic ganglion)
•Acute type A aortic dissection was complicated by cardiac tamponade in 19% of patients
ELDERLY -presentation
•more likely to have atherosclerosis, prior aortic aneurysm,iatrogenic dissection, or intramural hematoma
•Less likely to have the abrupt onset of pain or any pulse deficit or a murmur of aortic regurgitation
•less likely to undergo surgery•had a higher mortality with either surgery
or medical therapy.
Diagnosis
•Thoracic Dissection▫90% have abnormal CXR
Widened mediastinum Abnormal aortic contour Pleural effusion Deviation of trachea, mainstem bronchi, or
esophagus Intimal calcium visable & distant from edge
(calcium sign)
CT 83-100% sensitive 87-100% specific CT with IV contrast Will not give anatomic details of arterial branches or aortic valve competence.
Modality of choice in unstable patient
Angiography
“Gold standard” Shows all anatomy and involvement 94% specific 88% sensitive
TEE
97-100% sensitive97-99% specificEsophageal dz contraindication
ED Treatment▫Treat hypertension
-blocker Esmolol 500g/kg IV bolus over 1 minute then
50-150 g/kg minute Metoprolol 5mg q2min x3 IV then 2-5mg/hr Propranolol 20mg IV then 40mg, 8-mg q10min
to 300mg total Calcium channel blocker if -blocker
contraindicated
Treatment ▫Vasodilator
Nitroprusside 0.3 g/kg/min IV▫Surgery
OR for ascending aortic dissection Descending aortic dissection worse surgical
risks –controversial for repair
Thank you!
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