From the Guidelines
Pre-hospital management of acute aortic dissection should focus on rapid recognition, stabilization, and expedited transport to a capable facility, with immediate blood pressure control targeting a systolic blood pressure of 100-120 mmHg and a heart rate of less than 60 beats per minute. This approach is supported by the most recent and highest quality study, which recommends the use of intravenous beta-blockers as the first-line treatment for acute aortic dissection in the pre-hospital setting 1.
The management of acute aortic dissection in the pre-hospital setting involves several key components, including:
- Immediate blood pressure control using intravenous beta-blockers, such as labetalol or metoprolol, to reduce heart rate and blood pressure, thereby decreasing shear forces on the aortic wall 1
- Pain management with morphine to reduce sympathetic drive and prevent increases in blood pressure 1
- Establishment of two large-bore IV lines, administration of supplemental oxygen to maintain saturation above 94%, and placement of the patient in a position of comfort
- Continuous cardiac monitoring, frequent vital sign checks, and 12-lead ECG to quickly identify any changes in the patient's condition
- Avoidance of unnecessary movement and procedures that might increase blood pressure
In cases where beta-blockers are contraindicated or insufficient, alternative options such as nitrates, sodium nitroprusside, or calcium channel blockers may be used 1. However, beta-blockers should be started before other anti-hypertensive drugs to avoid reflex tachycardia. The goal of pre-hospital care is to prevent extension of the dissection and aortic rupture while rapidly delivering the patient to definitive care, which often requires surgical intervention.
It is essential to note that the treatment of acute aortic dissection may be complex, especially in the presence of complications such as stroke, tamponade, mesenteric ischemia, acute aortic regurgitation, MI, or cardiogenic shock 1. Therefore, expedited transport to a center with cardiothoracic surgical capabilities is crucial to ensure the best possible outcomes for patients with acute aortic dissection.
From the Research
Pre-Hospital Management of Acute Aortic Dissection
The pre-hospital management of acute aortic dissection involves prompt and effective control of blood pressure and heart rate.
- The primary goal is to reduce shear stress on the aortic wall to prevent rupture and minimize progression of the aortic wall injury 2, 3.
- Current therapeutic guidelines recommend medical therapy with aggressive blood pressure lowering for patients with acute aortic dissection, when they are not indicated for emergency surgery 2.
- Beta-blockers, such as esmolol, are commonly used to control heart rate and blood pressure in patients with acute aortic dissection 4, 5.
- Esmolol, an ultrashort-acting beta-blocker, has been shown to be effective in achieving lenient heart rate control in patients with acute aortic dissection, with minimal risk of hypotension 4, 5.
- Sodium nitroprusside is also used in combination with beta-blockers to control blood pressure in patients with acute aortic dissection 5, 6.
Key Considerations
- Prompt diagnosis and intervention are crucial to prevent mortality in patients with acute aortic dissection 2, 3.
- Understanding the pathophysiological anatomy that can induce organ malperfusion is important for early diagnosis and intervention 2.
- The management of acute aortic dissection requires a multidisciplinary approach, involving emergency medicine, cardiology, and vascular surgery specialists 6, 3.