From the Guidelines
Management of aortic dissection following trauma to the back requires immediate medical stabilization with blood pressure control using intravenous beta-blockers, such as labetalol or esmolol, to maintain systolic blood pressure between 100-120 mmHg, as well as pain control and fluid resuscitation to maintain organ perfusion. The initial management should focus on reducing aortic wall stress by controlling heart rate and blood pressure, as recommended by the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1.
Key aspects of management include:
- Blood pressure control with intravenous beta-blockers, such as labetalol (10-20 mg IV bolus, followed by 0.5-2 mg/min infusion) or esmolol (500 μg/kg loading dose, then 50-200 μg/kg/min) to maintain systolic blood pressure between 100-120 mmHg 1
- Pain control with opioid analgesics
- Fluid resuscitation to maintain organ perfusion
- Urgent surgical consultation for operative repair, with endovascular repair with stent grafts being the preferred approach when feasible, offering lower mortality rates compared to open surgical repair 1
- CT angiography as the diagnostic modality of choice to evaluate the extent of dissection and guide treatment decisions
- Close hemodynamic monitoring in an intensive care setting throughout management
The urgency of intervention depends on the location and extent of dissection, with Stanford Type A (involving the ascending aorta) requiring immediate surgery, while some Type B dissections (descending aorta only) may be managed medically if uncomplicated 1. Traumatic aortic injuries carry high mortality rates, making rapid diagnosis and treatment critical for survival.
In cases of complications, such as stroke, tamponade, mesenteric ischemia, acute aortic regurgitation, MI, or cardiogenic shock, treatment may be complex, but immediate operative management is often necessary 1. Hypotension or shock in the setting of aortic dissection suggests the need for immediate operative management, and pericardiocentesis may be performed in cases of hemopericardium and cardiac tamponade to restore perfusion 1.
From the Research
Management of Aortic Dissection
The management of aortic dissection following trauma to the back involves a multidisciplinary approach, with treatment depending on the severity and location of the dissection 2.
Treatment Options
- Open surgical repair is the gold standard of treatment for dissections located in the proximal part of the aorta and the arch 2.
- Endovascular interventions are recommended for most distal or type B aortic dissections 2.
- Thoracic endovascular aortic repair (TEVAR) may be a viable rescue option for patients with type A dissection who are not eligible for open surgical repair 3.
Medical Therapy
- Beta-blockers are commonly used as first-line therapy to decrease aortic wall stress in patients with chronic type B aortic dissections 4.
- However, there is limited evidence to support the use of beta-blockers in non-surgical patients with type A aortic dissection, and some studies suggest that they may actually exacerbate the condition 5.