Morning Report: Aortic Dissection - Dr. Gibbs

Case: 55 year male several hours crushing chest pain.  Medic ECG shows inferior STEMI with reciprocal ST depression.  Patient is Hypertensive. Sats 90%.  CXR with BL edema.  Trop 4.5, Lactate 6.7, Cocaine positive.

AORTIC DISSECTION WITH STEMI

• Looking at the edema, diastolic murmur, acute chest pain in patient with HTN, this appears to actually be dissection with inferior wall MI and aortic insufficiency

• Aortic insufficiency Murmur:  Early diastole, decrescendo, on the left

• Initial diagnosis correct 15-50%, delay in >40%.  Mistakenly giving lytics can be disasterous!

• Consider aortic dissection if chest pain patient has neurologic symptoms (ex, CVA, paraplegia, paretic extremity), acute abdomen, renal failure.  Also if acute CHF, syncope.  

• Tx: Control blood pressure and heart rate.  Beta blocker (Esmolol, labetalol).  Pain relief.  HOWEVER should not beta blockade in acute aortic insufficiency.  Consider afterload reduction like nitroprusside, use beta blockade only if reflex tachycardia.
  

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