Aortic Dissection

50yo M transfer from OSH with aortic dissection based on CT scan from carotids/proximal aorta (Type A) to iliacs bilaterally.  Sx were sudden-onset CP radiating to back and neck and presyncope.  No recent illnesses, abd pain.  Bradycardic on arrival (40’s) with stable BP, was on nitroprusside gtt.  Mental status was fluctuating but he was protecting his airway.  Cardiac surgery immediately consulted on arrival to TB.
Initial labs:
Hgb 12.3, INR 1.1, WBC 23.6, chem7 wnl, ABG 7.15 / 60 / 207 / 22 / 99%
Type A dissection repaired by cardiac surgery on 11/9/12, post-op complications of AKI, post-op resp failure, afib, remains in ICU at this time in fairly critical condition, getting TF and intubated
1.      Aortic dissection classic presentation IS NOT the way most people present!  According to the IRAD study, the following are the percentage occurance of the classic symptoms. n= 464 patients
a.      Ripping or tearing CP = 50%
b.      Migrating pain = 16.5%
c.      Radiating pain = 28%
d.      Posterior pain = 36%
e.      Any pain at all = 95.5%  What??  4.5% have no pain?
f.      Sharp pain = 65%
g.      Abdominal pain = 30%
h.      Pulse Deficit = 15%
i.      CXR totally normal = 12.5% ; Absence of wide mediastinum 21%
So what’s the point…aortic dissection does not always present the way you are taught it does!!!  Colin’s opinion:  “I have never seen an AD (n=8 denovo and ? 10+, transfers) that did not give some appearance that something really bad is happening…might not know exactly what, but definitely something very bad!”
2.      According to Dr. John A. Elefteriades MD (Cardiology 2008;109:263–272*):  A thoracic surgeon and one of the world’s experts on AD (His legal opinions generally defens docs in AD cases and serve as “precedent in court” )…
*“Litigation in Nontraumatic Aortic Diseases” by John A. Elefteriades (Cardiology 2008;109:263–272)
“In fact, difficulty in diagnosis, delayed diagnosis or failure to diagnose are so common as to approach the norm for this disease, even in the best hands, rather than the exception.”
3.      A negative D-dimer in suspected aortic dissection is probably very good in excluding an aortic dissection in the low pre-test probability patient…BUT it is not either definitively proven (as much as anything can be) or generally accepted as a reasonable “standard of care” test in this setting.  SO WHAT DOES THIS MEAN FOR ME…not ready for “prime time…yet!”
4.      The “CHEST PAIN…AND… SYNDROME” = CP + CVA = Carotid Dissection; CP + AP = descending aortic dissection.  Maybe “equals” is too strong, but maybe “you must think of” is a perfect way to frame this thought.
5.      Type A = Ascending Aorta = Surgical.  Type B = Descending aorta only.
6.      ABCDE:  A=Airway; B=Breathing; C= CT scan; D=Dial the CT/Vasc surgeon; E=Esmolol; F=Facilitate other BP control.
7.      BP control = decrease dP/dT:  Change in pressure over time.  Beta blocker + vasodilator is what we currently use at OSU.

-Despite advances in medicine over the years, this remains very high mortality