aortic dissection

[chef]

i hear there's no warning signs or anything like that.. but when a pt gets admitted b/c of chest pain (i know it's not very specific), wouldnt a simple cxr or ct show signs of hemmorhage? i dunno if cbc would help b/c this is such an acute event.

but i heard for example j ritter was admitted around 3 pm and they dx'ed a.d. and did the surgery around 2am.. they had close to 11 hrs?? they couldn't figure it out?

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[ckent]

Don't know what John Ritter presented with, but my hospital likes to do CT's with contrast for just about everyone who complains of ripping chest pain that goes from the chest to the back. Supposedly, the best test to get is a transesophageal echocardiograph because of it's high sensitivity and specificity, but I suspect that there are new/are working on new studies with high res CT's to see if they can improve the sensitivity and specificity. Ct's are nice because they are non-invasive, pt's have to be npo (nothing by mouth) for several hours before you can get a TEE too so it's not as fast in the ER, plus you have to wait for a cardiologist to get to the ER. I suspect that John Ritter may have had something that predisposed him to get an AD (like a bicuspid aortic valve) because I doubt that he was all that hypertensive based on his age and body habitus, so I suspect that the hospital just didn't suspect aortic dissection until it was too late. Maybe he never went to a doctor, so they sat on him for several hours trying to r/o MI because they didn't know his cardiac risk factors. They probably only decided to scan him after he kept complaining of chest pain with a normal ECG. I'm surprised to hear that they didn't scan him earlier to tell the truth, I'm sure that he was assigned "VIP" status. No one likes to have a celebrity die in their hospital from a missed diagnosis or mismanagement, it's obviously bad publicity.

 

[DrQuinn]

Thought he collapsed on the set...

Q, DO

 

[kcrd]

According to People magazine he had chest pain, nausea and vomiting, and abdominal pain.

 

[Winged Scapula]

Now I can't recall the location of his dissection, but not all thoracic ADs require surgery. Ritter's trip to the OR may have been delayed by many factors: controversy over whether or not to oeprate, inability to manage the dissection medically (ie, keeping his BP low), an extension of the AD which then required surgery, unavailability of a CT surgeon, etc.

The definitive treatment for Type B uncomplicated distal dissections may be medically to control blood pressure. Distal dissections treated medically have the same or lower mortality rate as those treated surgically. Surgery is usually reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ. Inability to control hypertension with medication is also an indication for surgery in those with a distal thoracic aortic dissection (although I agree his body habitus wasn't one usually associated with HTN, you never really know).
Long-term medical therapy involves a beta-blocker combined with other antihypertensive medications.

At any rate, I'm not sure why it took them 11 hours to get him to the OR (or did he die at 2 am?) but there are lots of plausible reasons (as well as some inexcusable ones).

 

[droliver]

Originally posted by ckent
Supposedly, the best test to get is a transesophageal echocardiograph because of it's high sensitivity and specificity,

You can see most of them on CT. When I was taking care of a few during general surgery, I was told by the Cardiologist & CT fellows that the TEE was useful for deliniating whether the origin was either proximal or distal to the takeoff of the left Subclavian Artery which would decide Medical vs. Surgical tx. at our institution. There is a school of thought that they should all be operated on ( I think this was started @ Stanford U.), but I think most places only operate on the Proximal one's. Distal disections are pretty frustrating...... you sit and watch and you can tell the disection is propagating as the LFT's climb and then the Creatinine bumps as the takeoff of the celiac/SMA and renal arteries become involved with it. It is a truly horrible and helpless feeling and one of the things I remember most from my ICU training.

 

[Winged Scapula]

Interestingly (and timely) enough, I was just consulted to place an A-line in a gentleman in our MICU with a HUGE Ao dissection. On CT starts at the distal takeoff of the L Subclavian and extends through to the Right Common Iliac! According to the patient, was told by the radiologist "the biggest one I've ever seen". Not good when a physician tells you something like that.

As droliver notes, its a pretty scary/sickening process watching these guys. Right now he's on Nipride and Esmolol drips and all his regular anti-HTN meds.

 

[stoic]

What about a simple cxr to check the width of the mediastinum (sp)? An ER group I'm familier with gave "catch of the month" to one of it's docs for spotting a massive dissection in a 73yo male c/o flu like sx and mild pain between his shoulders on a plain film cxr.

By the way, I'm completely unqualified to know whether or not cxr thing is standard procedure/useful... just thought I'd post the story.

 

[souljah1]

any thoughts on the relationship of chronic cocaine use and ADs? I'm not implying that Mr. Ritter was a long-time user, but it did come to mind as a thought - especially since he was in the thick of Hollywood in the late 70's and 80's. I think I remember hearing that there was an association between cocaine use (may have just been crack cocaine) and dissections. anyone?

 

[ckent]

Originally posted by souljah1
any thoughts on the relationship of chronic cocaine use and ADs? I'm not implying that Mr. Ritter was a long-time user, but it did come to mind as a thought - especially since he was in the thick of Hollywood in the late 70's and 80's. I think I remember hearing that there was an association between cocaine use (may have just been crack cocaine) and dissections. anyone?

I'm sure that there probably is an association as cocaine--> vasoconstriction--> hypertension-->aortic dissection.

You'd have to have a fairly significant dissection associated with some sort of aneurysm in order to see it on CXR, it has a very low sensitivity for picking it up meaning that if that's your screening tool, you'd miss a lot of patients who had AD. Getting a cxr is part of a standard w/u of anyone who presents with chest pain, but it's not for ruling out aortic dissection. Great if you see it, meaningless if you don't.

 

[souljah1]

http://www.americanheart.org/presenter.jhtml?identifier=3001185


I actually did a quick search ckent and found this. I knew it sounded familiar.

 

[stoic]

Do patients ever go on to lead full, healthy lifes after an aortic dissection?