← Diagnosis and Management Guides
Aortic Dissection
Key considerations: Stanford Type A (ascending) — surgical emergency, Malperfusion syndrome, Cardiac tamponade
Cannot miss
- Stanford Type A (ascending) — surgical emergency
- Malperfusion syndrome
- Cardiac tamponade
- Aortic rupture
Likely diagnoses
- Acute aortic dissection
- ACS
- PE
- Musculoskeletal pain
- Esophageal rupture
Red flags
- Sudden tearing chest/back pain
- Pulse deficit
- New aortic regurgitation murmur
- Widened mediastinum
- Hypotension
Workup
- history: Sudden severe chest or back pain (tearing/ripping), radiation, Marfan/Ehlers-Danlos, HTN, cocaine use; exam: Bilateral BP (>20mmHg difference), new diastolic murmur (AR), pulse deficits, neuro exam; labs: D-dimer (high sensitivity if <24hr); CBC, BMP, troponin, type and screen; imaging: CT angiography (chest/abdomen/pelvis) — gold standard; TEE if too unstable for CT; CXR: widened mediastinum (sensitivity only ~60%); bedside: Bilateral BPs, POCUS for pericardial effusion and aortic root dilation
Management
- immediate: HR control FIRST: esmolol drip (target HR <60); THEN reduce SBP to <120 (nicardipine or nitroprusside); Type A: emergent cardiac surgery; Type B uncomplicated: medical management in ICU; general: Avoid beta-blockers? NO — they are first-line; Pain control (morphine); Serial imaging; Long-term: BP control, surveillance imaging
Disposition
- admit: All aortic dissections to ICU; discharge: Never acutely; consults: Cardiac/vascular surgery emergently for Type A, vascular surgery for complicated Type B
Clinical pearls
- Type A (ascending): surgery or death. Type B (descending): medical management unless complicated
- Reduce heart rate BEFORE vasodilators — vasodilators alone cause reflex tachycardia and increase aortic wall shear stress
- D-dimer <500 within 24hr of onset has ~97% sensitivity for ruling out dissection (ADD-RS + D-dimer strategy)
Source and review
- AHA/ACC Aortic Disease Guidelines 2022. Last reviewed: 2024-11-01