Ultrasound images and text Genevieve Carbonatto
A 56 year old lady presents to the Emergency department with a history of severe abdominal pain. She woke up to go to the toilet and while sitting developed sudden paraesthesia in both her thighs associated with severe back pain and abdominal pain. She noticed that her left leg was somewhat weak. She presented a month ago with similar back pain. She has been investigated for a month for abdominal pain which she describes as similar to what she is experiencing on arrival to the ED. She is due to see her gastroenterologist for a gastrosopy and a colonoscopy. A CT aortogram is ordered instead to exclude dissection
This is the CT aortogram.
She has a Standford type A aortic dissection with left renal infarcts from dissection involving the left renal artery. There is an occlusion of the distal abdominal aorta to the bifurcation extending to the proximal left common iliac artery. There was recanalisation of the left common iliac artery distally and flow was demonstated in the lower limb arteries explaining the warm legs.
This is her focused point of care ultrasound
PLAX more dedicated aortic root view.
PLAX view with colour showing aortic regurgitation. Note there is no pericardial effusion.
Size of aortic root 4.99 cm
Proximal abdominal aorta in transverse shows dissection flap.
The proximal aorta in the longitudinal plane also shows the dissection flap.
Discussion
Aortic dissection is often missed in the Emergency Department (1,2,3) on initial presentation, figures range from 15 – 43%. The location of pain is the most predictive factor for diagnosing aortic dissection , back and chest pain being the most predictive for accurate diagnosis, abdominal pain the least predictive for accurate diagnosis. Aortic dissection is 3 X more common than AAA rupture. (4) It is however uncommon, 1 in 10,000 ED patients will have aortic dissection. Only 1/4 present with classic features (2) of sudden onset of severe pain, BP differential and widened mediastinum on chest Xray. 1 in 25 patients have none of the classic features of dissection. Untreated, the mortality of an aortic dissection is 40% on presentation and 1% rate of death per hour
Clinical presentation
- Pain 90% of cases – severe and rapid onset. May be migratory.
- Sites of pain : chest, thoracic or lumbar back pain, abdominal pain
- Focal neurological signs 17 % – limb paraesthesia or weakness
- Syncope 9%
- SOB, haemoptysis (extremely rare presentation)
- Pulse deficits
- Hypertension – (aortic dissection is one of the cardinal hypertensive emergencies)
- Hypotension associated with cardiac tamponade or free rupture
Diagnosis
- Chest Xray – mediastinal widening , not present in 10 -20% of cases
- ECG – signs of longstanding hypertension , myocardial ischaemia or infarction if the dissection is extending into the coronary arteries
- CT aortogram confirms extent of dissection and may help with the differential diagnosis if dissection is excluded
- MRI if patient stable or if patient has a known severe iv contrast allergy
- Ultrasound – Limited by patient, operator and machine. Remember that 80% of aortic dissections are in non aneurysmal vessels.
Treatment
The aim is to limit the progression of the dissection. This is achieved by reducing the kinetic energy of the blood flow by reducing blood velocity and decreasing the pressure differentials throughout the aorta. Therefore the aims are to
- Reduce BP to 100- 120mmHg
- Reduce HR to 60 -80/min
- Control bleeding
- Fluid resuscitate
Practically, call cardiothoracics and
- insert iv line
- Xmatch 6 units of blood
- Activate massive transfusion protocols if present in your institution
- Correct coagulopathy
- Give iv opiates
- Control BP and HR by B blockade. Titrate Metoprolol 2.5 mg – 5mg iv or Propranolol 1 – 3mg iv to BP of 120mmHg
Teaching point: The diagnosis of aortic dissection can be difficult. It is one of the great “mimickers” along with AAA. If you think about it ultrasound can be helpful however be aware that the aorta will most likely not be aneurysmal and it may be difficult to see a flap.
References
- J Cardiol .2011 Nov;58(3):287-93.Sep 3.Factors leading to failure to diagnose acute aortic dissection in the emergency room.Kurabayashi M1, Miwa N, Ueshima D, Sugiyama K, Yoshimura K, Shimura T, Aoyagi H, Azegami K, Okishige K, Isobe M.
- Curr Cardiol Rev. 2012 May; 8(2): 152–157. Screening, Evaluation, and Early Management of Acute Aortic Dissection in the ED Reuben J Strayer,* Peter L Shearer, and Luke K Hermann
- Am J Cardiol. 2007 ;99(6):852–856. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Hansen MS1, Nogareda GJ, Hutchison SJ.
- LIFL Acute aortic dissection
- Am J Emerg Med.2000 Jan;18(1):46-50. Diagnosis of acute thoracic aortic dissection in the emergency department. Sullivan PR1, Wolfson AB, Leckey RD, Burke JL.
- JAMA 2002 May 1;287(17):2262-72.Does this patient have an acute thoracic aortic dissection? Klompas M1.
- Ann of Emerg Med: 2015 Jan;65(1):32-42.e12. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thoracic Aortic Dissection, Diercks DB, Promes SB, Schuur JD, Shah K, Valente JH, Cantrill SV.
- Emerg Med Clin North Am: Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management.Upadhye S1, Schiff K.
- Lung Ind. 2008 Jan-Mar; 25(1): 20–21. HAEMOPTYSIS – A RARE PRESENTATION OF AORTIC ANE URYSM
Girija Nair, MD, Professor,1 Savita Jindal, MD, Registrar,2 Abehishek Chandra, MBBS, Resident,3 Shivani Swami, Resident,3 and Pankaj Garg, MBBS, Resident3