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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