Archive | June, 2016


27 Jun

submitted by Christina Brown, M.D.

Definition – Blood entering intimal tear in aortic wall.  Blood subsequently dissects through the media under aortic systolic pressure.

Risk Factors – HTN, Tobacco abuse, pregnancy, congenital heart disease (bicuspid AV, Coarctation), Marfan’s, Ehler’s Danlos, Inflammation (Lupus, syphilis, endocarditis, GCA)



Proximal – Occur at the aortic root, coronary ostia and/or pericardium.  

Distal – Dissect distally to involve any or all branches of the aorta ie -carotid and subclavian arteries.

Stanford classification:

  • Type A: Ascending aorta
  • Type B: Distal to ascending aorta

Peak Age for Occurrence

  • Proximal dissection: 50–55 yr
  • Distal dissection: 60–70 yr


  • Occlusion of the coronary ostia, aortic valve incompetence, or cardiac tamponade.


Signs & Symptoms

Chest Pain:

  • May be absent in as many as 15% of patients
  • Acute onset, sharp
  • Substernal -> type A dissection
  • Intrascapular -> descending thoracic dissection
  • Lumbar -> abdominal aorta involvement

Back pain:

  • Commonly interscapular or lumbar. May present as combination of chest, back, and abdominal pain.

Neurologic complaints: Stroke symptoms, Vision changes


Physical Exam

Hypertension: 35–40% may be normotensive.

Pulse deficits: Discrepancies in BP in upper extremities

Neurologic/spinal cord deficits

New murmur of aortic regurgitation: Occurs in up to 31% of patients



EKG – Dissection may involve coronary ostia and cause MI:

  • Inferior MI (RCA territory) is more common than LCA territory.
  • A normal EKG + severe, acute-onset chest/back pain/shortness of breath – high suspicion for aortic dissection.


  • CBC, BMP, UA – Evaluate renal function, hematuria
  • Amylase – May be elevated d/t bowel ischemia
  • Troponin – May be elevated d/t myocardial ischemia



Unstable Patient:

CXR – Widened mediastinum or abnormal aortic contour.

Echocardiogram – Transthoracic vs Transoesophageal (if intubated) – Tamponade, valvular incompetence for evaluation. 

Stable Patient:  CT, Aortography


ED Treatment

BP Control = Reduce shear force on aortic wall and slow down the dissection process.

  • Esmolol (IV) or labetalol (IV): Start before Nitroprusside therapy to prevent reflex tachycardia. 
    • Contraindications:Bradycardia,  COPD, hypotension
  • Nitroprusside


Emergent surgery:

  • Treatment of choice for type A dissection
  • Treatment for type B dissections in those who have failed medical therapy

Medical management:

  • Treatment of choice for stable type B dissections



ADMIT – All patients with an evolving aortic dissection should be admitted to the ICU.  C/S  cardiothoracic surgery for type A dissection.



1] Jeffrey I. Schneider and Jonathan S. Olshaker.  Aortic Dissection, Thoracic. Rosen & Barkin’s 5-minute Emergency Medicine Consult.
2] Erbel R, Alfonso F, and Boileau C et al.: Diagnosis and management of aortic dissection. Eur Heart J. 2001; 22(18):1642–1681. [PMID: 11511117]
[3] Hagan P G, Nienaber C A, and Isselbacher E M et al.: The international registry of acute aortic dissection: New insights into an old disease. JAMA. 2000; 283(7):897–903. [PMID:10685714]
[4] Khan I A and Nair C K.: Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002; 122(1):311–328. [PMID: 12114376]
[5] Klompas M.: Does this patient have an acute thoracic aortic dissection? JAMA. 2002; 287:2262–2272. [PMID: 11980527]
[6] Mészáros I, Mόrocz J, and Szlávi J et al.: Epidemiology and clinicopathology of aortic dissection. Chest. 2000; 117(5):1271–1278. [PMID: 10807810]
[7] Moore A G, Eagel K A, and Bruckman D et al.: Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International registry of acute aortic dissection. Am J Cardiol. 2002; 89:1235–1238. [PMID:12008187]


tox bradycardias: fingerstick for clues

7 Jun

often taught, often forgotten clue to help differentiate beta-blocker vs. calcium channel blocker overdoses:


Calcium Channel Blockers can present with hyperglycemia (CCBs prevent insulin release)

Beta Blockers can present with hypoglycemia (BBs  inhibits both glycogenolysis and gluconeogenesis)



The above difference has been difficult to remember for me, and I frequently look it up as a reminder, so here’s an attempt to associate/remember which is which:



visual association:








Appreciate any other tips/mnemonics y’all have on remembering the difference.  


References: emdocs post, beta blocker, ODs, picture 1, 2, 3



tendon repair – Kessler stitch

2 Jun

via a nice quick review of tendon lac repair concepts in last December’s ACEP Now:

modified Kessler stitch for tendon repair:

basic idea: stronger stitch, tension distributed across multiple points (e.g. with mattress sutures)

the stitch:


concept walkthrough (tune in from 2:00-4:00 if tight on time):

live action video (start at 0:30 if tight on time)

There you go. Add one more technique to the toolbox.


References: ACEP Now article (& picture); concept video; live video