aortic dissection- morning report
DESCRIPTION
Aortic dissection- case report (for morning report)TRANSCRIPT
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Morning Report
Diana GirnitaMD, PhD
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94 yo White female admitted in the ER
CC: Shortness of breath
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What would you like to know?
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•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
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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
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PMH• HTN. Hyperlipidemia . CHF• Arthritis • Breast cancer s/p Left masectomy with
lymph node removal• Urinary Incontinence• GERD • Hearing loss• Asthma • Cataract • Anxiety
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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
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FH and Social
•FH not significant•Social: not a smoker, no EtOH, no ilicit
drugs, retired, former dancer
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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% |
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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
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Differential diagnosis
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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
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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
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Labs
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•CBC•BMP•Cardiac enzymes•D-dimers•Liver profile•BNP•LA
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ECG 12/19/11 – did not differ from previous admission
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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
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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
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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.
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What to order next?
CXRV/Q scan CTPA
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CXR 12/19/11
•Significant reduction in bilateral effusions and lower lung airspace disease since previous exam
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V/Q scan 12/19/11
•Intermediate probability pattern for pulmonary embolus
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What is the next step?
ECHO CT chestLEs venous doppler
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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.
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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
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Consults
•Cardiology•Thoracic surgery•Palliative care
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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
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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
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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
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Aortic Dissection
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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
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Common presenting group
▫>50 yo with HTN▫2/3 male▫Marfan’s syndrome▫Congenital heart disease▫Pregnancy
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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!
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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
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Physical Exam▫Usually normal heart and lung exam▫May have aortic insufficiency▫<20% with decreased radial, femoral or
carotid pulse▫HTN/ hypotension▫Tachycardia
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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
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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.
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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)
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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
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Angiography
“Gold standard” Shows all anatomy and involvement 94% specific 88% sensitive
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TEE
97-100% sensitive97-99% specificEsophageal dz contraindication
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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
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Treatment ▫Vasodilator
Nitroprusside 0.3 g/kg/min IV▫Surgery
OR for ascending aortic dissection Descending aortic dissection worse surgical
risks –controversial for repair
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Thank you!