1. Peter Cheng AORTIC DISSECTION

2. IRAD 12 referral centres 646 patients 1996 -1998

3. AORTIC DISSECTION Wide clinical spectrum Chest pain most common 72.7% Tearing/ripping were not characteristic descriptors Abrupt onset 84.8% and severe 90.6% Migrating 16.6% Abdo pain 29% Back pain 53% Syncope 9.4% No other neuro deficits Hypertension 70% Type B, 35.7% Type A Hypotension = tamponade UPO Aortic regurg murmur in half ECG normal in 31%

5. CXR CXR findings Mediastinal widening Left paraspinal stripe Displacement of intimal calcifications (calcium sign) Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube 63% sensitive for widened mediastinum Completely normal in 12.4%

7. US Limited role as a bedside test except to rule out pericardial tamponade Aortic regurg (doppler) Intimal flap may be seen using parasternal and suprasternal view Transoesophageal (TOE) very sensitive but less accessible than CT

8. TREATMENT Overall mortality 27.4% Type A Surgery reduces mortality from 58% to 26% Type B Surgery worsens prognosis from 10 – 31%!! Majority successfully managed medically BP control Reduced wall stress Beta-blocker eg esmolol aiming for 60bpm / systolic 120mmHg +/- IV antiHT Fentanyl 25-50mcg Urgent transfer to CTS

9. AD VS AMI Due to dissection of R or L coronary arteries Needs robust discussion with Cardiologist Poor eGFR must not hinder emergent CT aortogram Hypotension Tamponade Myocardial ischaemia Aortic insufficiency Withhold thrombolytics/heparin

10. ALWAYS … Palpate bilateral radial pulses Measure bilateral BPs

11. http://emcrit.org/podcasts/aortic-dissection/