SHORT CASE

krit Kuruchaiyapanich R2

5 hospital conference : 1st

@ Rajavithi hospital

17 June 2010

History

An elderly Thai female 80 years oldChief complaint: Progressive

dyspnea for 2 weeks

History

Present illness- 8 months ago, the patient presented with acute dyspnea .Chest X-ray was shown left pleural effusion size 7*4 cm, trachea in midline, no widening mediastinum. She was diagnosis tapped left pleural effusion. Gross blood was shown.The doctor planned CT Chest for rule out malignancy but she loss follow up.

History (con’t)

Present illness- 2 weeks ago, she was progressive dyspnea on exertion, no chest pain, +ve PND, no orthopneano back pain, no fever, no dizziness

History

Past illness:- underlying disease: Ischemic stroke (right hemiparesis) since November 2004 , HT - medication: ASA(325) 1*1 pc, Enalapril(20)1*2 pc, Zimmex(10) 1*1 hs- no Hx trauma- no Hx drugs allergy , no smoking, no alcoholic drinking

Physical examination

VS: afebrile, BP 170/123 mmHg, PR 106/min, RR 30/min, O2 sat RA= 95%

General appearance: ill-appearing but alert and in no apparent distress

Heart : Neck vein engorged,normal S1 and S2 and no murmurs, rubs, or gallops, The peripheral pulses are strong and symmetric in all four extremities.

Lungs : decreased breath sound at left lung

Physical examination

Abdomen : Soft and non tender,ill-defined palpable mass at epigastrium ,no organomegaly is detected

Extremities : No edema or erythema both legs and no deformity, mild pitting edema

NS : WNL

Investigation (31/5/2010)

Investigation (31/5/2010)

Ultrasound bedside

Echocardiogram( 7th June 2010)

Good LV systolic contraction(EF 80 %), massive pericardial effusion Anterior= 27.2 mm, Posterior= 10.7 mm, no RV collapse, Calcified three cusps of AV with moderate AR(jet area= 45% of LVOT), no AS, normal coaptation of mitral leaflets with no MS, no MR, mild TR with estimated RVSP= 25, no clot can seen

CT Plain

Result

Type B dissecting aneurysm of the descending aorta down to aortic bifurcation with rupture.

Compression of true lumen at level of below left renal a.

Aneurysmal dilatation of the ascending aorta with peripheral thrombus.

Hemorrhagic pericardial effusion with impending pericardial tamponade.

Diagnosis

Type B dissecting aneurysm of the descending aorta with hemorrhagic pericardial effusion

Treatment At ER

O2 canula 3 LPMClosed up monitor vital signsEchocardigram searched for cardiac

temponadeNPO0.9% NaCl 1,000 ml sig IV drip in 40

ml/hrEmergency CT whole aorta

Aortic disection

Epidemiology

More often in men and increases with age.

Hypertension: most common risk factor.

Mortality is 1 - 5 / 100,000 population per year.

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

Classification

The Stanford classification Type A dissections involve the

ascending aorta Type B dissections do not

Distal dissections tend to be older, heavy smokers with chronic lung disease and more often with generalized atherosclerosis and hypertension.

acute (< 2 weeks) and chronic (> 2 weeks). Rosen’s Emergency medicine: Concepts and Clinical

Practice, 6th Edition

Classification

Management

Airway, Breathing, CirculationBlood pressure should be measured

all four limbs. Patients presenting with hypotension

secondary to aortic rupture or pericardial tamponade should be resuscitated with intravenous fluids and immediately transported to the operating room if they are to have a chance to survive. Rosen’s Emergency medicine: Concepts and Clinical

Practice, 6th Edition

Management

The two goals of medical management are to (1) reduce blood pressure and (2) decrease the rate of rise of the arterial pulse (dP/dt) to diminish shearing forces

Opioids pain control and to decrease sympathetic tone.

The use of β-adrenergic blockers is the cornerstone of aortic dissection management target HR is 60-80/ min

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

Management

Sodium nitroprusside can be used, in conjunction with a β-blocker, to maintain the systolic blood pressure at 100 to 120 mm Hg or to the lowest level to maintain vital organ perfusion.

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

Surgery

Type A acute aortic dissections require prompt surgical treatment.

Definitive treatment of type B acute aortic dissections is less clear. Sx for persistent pain, uncontrolled hypertension, occlusion of a major arterial trunk, frank aortic leaking or rupture, or development of localized aneurysm.

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

Prognosis

A “Deadly triad” 1. absence of chest pain 2. hypotension 3. branch vessel involvement

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

Interventional Therapy

Stent-graft and fenestration technique for complicated type B dissections

Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

THANK YOU