A 67 year old male with pmhx of a thoracic aortic aneurysm, diabetes, and hypertension presents with two hours of chest pain radiating to his jaw and back. The patient tells you he was standing in his kitchen when the pain came on suddenly. He felt nauseated and sweaty and called 911. On exam he appears uncomfortable. His temp is 98.7, RR 22, HR 85, BP 170/100, his ekg shows sinus rhythm at rate 85 with an old right bundle branch block and he has a glucose of 120.  

You obtain a CTA and you see the image below. What’s the diagnosis? (scroll down for answer)

Answer: Type A Aortic Dissection

• This patient has an aortic dissection involving the thoracic aorta
• Occurs after a violation of the intima allows blood to enter the media and dissect between the intimal and adventitial layers
• Bimodal age distribution
• Risk factors:
• connective tissue disease
• hypertension, hyperlipidemia, smoking
• pregnancy
• recent cardiac catheterization
• bicuspid aortic valve

• Classification systems: Stanford vs. Debakey
• Debakey:
• Type I- simultaneously involve ascending aorta, arch and descending aorta
• Type II- only ascending aorta
• Type III- only descending aorta
• Stanford:
• Type A- involves any portion of ascending aorta
• Type B- isolated to descending aorta (dissection that starts distal to L subclavian artery)
• CT aortogram is imaging of choice
• Management
• BP and HR management
• goal is to decrease "shear force" on the aorta-- goal systolic BP 100-120 mmHg and goal HR 60
• type A- immediate CT surgery
• type B- medical managment/surgery consultation

References:

 Johnson GA, Prince LA. Aortic Dissection and Related Aortic Syndromes. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.