What is the emergency management for suspected aortic dissection?

From the Guidelines

Emergency management for suspected aortic dissection requires immediate action to stabilize the patient and prevent catastrophic complications, with the primary goal of 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 1. The initial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling heart rate and blood pressure, with intravenous beta blockade being the first line of treatment, as stated in the 2010 guidelines 1.

• Key steps in the emergency management of suspected aortic dissection include:
  • Establishing large-bore IV access
  • Initiating aggressive blood pressure control with IV beta-blockers, such as labetalol or esmolol, to achieve a systolic blood pressure of 100-120 mmHg
  • Adding vasodilators, like nicardipine or nitroprusside, if beta-blockers alone are insufficient, but never using vasodilators alone as they can increase shear forces on the aortic wall
  • Providing adequate analgesia with IV opioids to reduce sympathetic drive
  • Obtaining immediate imaging with CT angiography, transesophageal echocardiography, or MRI to confirm the diagnosis
  • Simultaneously, typing and cross-matching blood, monitoring vital signs continuously, and preparing for potential surgical intervention
  • Avoiding unnecessary patient movement and maintaining the patient in a calm environment This aggressive approach aims to reduce aortic wall stress by decreasing blood pressure, heart rate, and the force of left ventricular contraction, thereby limiting extension of the dissection while preparations are made for definitive treatment, as supported by the guidelines 1 and other studies 1.

From the Research

Emergency Management for Suspected Aortic Dissection

The emergency management for suspected aortic dissection involves several key steps, including:

• Immediate imaging with chest computed tomography scan followed by transthoracic echocardiography (TTE) to confirm diagnosis 2
• Controlling the heart rate (60-80 beats/min), systolic blood pressure (100-120 mmHg), and pain 2
• Referring patients with Type A acute aortic dissection to cardiothoracic surgeons for emergency aortic surgery, while those with Type B acute aortic dissection should be referred to vascular surgeons for surgical/endovascular interventions if indicated 2
• Aggressive measures to lower the systemic blood pressure and its rate of increase (dP/dt), usually with intravenous beta-blockade in combination with sodium nitroprusside, should be instituted immediately, even before confirmatory imaging studies are performed 3

Medical Management

Medical management of acute aortic dissection includes:

• The use of intravenous beta-blockers, such as esmolol, to control heart rate and blood pressure 4, 5
• The use of sodium nitroprusside to control blood pressure 4, 3, 5
• The use of clevidipine as an alternative to sodium nitroprusside, which has been shown to be effective and less costly 5
• Strict antihypertensive therapy and a schedule of surveillance imaging studies should be established for hospital survivors 3

Importance of Timely Diagnosis

Timely diagnosis is crucial in the management of acute aortic dissection, as mortality increases from 1 to 2% per hour of elapsed time 6. A high level of suspicion and consideration of risk factors are essential in making a timely diagnosis.