Descending thoracic aortic dissection, next step? - USMLE Forums
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Old 09-12-2011
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Heart Descending thoracic aortic dissection, next step?

Hi guys I found this Q in the web, I would like to share it with .
A 55 yo male with longstanding hypertension, presented to ER with severe chest pain, tearing in nature & radiating to the back. An EKG revealed no significant abnormalities. A CT scan demonstrated descending thoracic aortic dissection to above the iliac bifurcation. Urine output is 45-55cc/h. Lower extremities were warm & pulsation was adequate, capill. refill- <2s.
What is most appropriate initial management?

A) Emergency operation to repair the dissection.
B) Angiography.

C) Echo.

D) Initiation of beta blocker.

E) Initiation of vasodilator
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Old 09-12-2011
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Emergency operation to repair dissection.......
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  #3  
Old 09-12-2011
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I think b. blocker.....

because generally descending aortic dissections r managed with control of b.p n ascending with surgery....
so out of options of medical management, vasodilators will cause tachycardia, n may worsen..so b blockers is the remaining choice....!!
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Old 09-12-2011
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Cool

Beta blocker for descending !

Good one !
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Old 09-12-2011
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Initial step is to give Beta-blocker to decrease heart rate and prevent massive hemorrhage. I believe the NEXT step would be to repair the dissection.
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Old 09-12-2011
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yes I too go with b blocker as given in kaplan ,for descending next step will be controlling bp n for ascending aorta dissection ,it will be emergency surgical repair.
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Old 09-12-2011
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Default Thoracic or abdominal

I don't quite understand: it's thoracic but ends at the iliac bifurcation? Must be huge then, no?
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Old 09-12-2011
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D) Initiation of beta blocker.
__________________
I'm Predictable In The Unpredictable Future !
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Old 09-12-2011
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The correct answer is D.
Right now there is no indication for emergency operation, because no end organ failure or rupture.
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Old 09-12-2011
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Some important fact about aortic dissection:
Classification: Type A (proximal) involves the ascending aorta (includes retrograde extension from descending aorta). Type B (distal) limited to descending aorta.
The best initial test is chest X ray: widening of the mediastinum.
The most accurate test is the angiogram (the most invasive).
The most important step in the treatment is the control of blood pressure, & this can be achieved with:
  • Beta blocker reduces the shearing forces that worsening the dissection, should be started before the vasodilator to protect from reflex tachycardia.
  • Nitroprusside.
  • Surgical correction.
Remember for type A dissection surgical management, for type B dissection, medical management.
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Old 09-13-2011
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so if type A is not associated with any organ failure or rupture then also we should proceed with surgery or approach is similar to type B?? and also management approach in both ascending and descending aortic dissection?

Last edited by Ace3; 09-13-2011 at 06:37 AM.
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Old 09-13-2011
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This good question, Confident: In conclusion the best management for type A aortic dissection is surgical for better outcome, I reviewed some article about that, if you like, have a look for this attached one.
Attached Files
File Type: pdf Type A aortic dissection.pdf (269.9 KB)
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