Medication Summary
Initial therapeutic goals include the elimination of pain and the reduction of systolic blood pressure to 100-120 mm Hg or to the lowest level commensurate with adequate vital organ (ie, cardiac, cerebral, renal) perfusion. Whether systolic hypertension or pain is present, beta-blockers are used to reduce arterial delta pressure/delta time (dP/dt).
To prevent exacerbations of tachycardia and hypertension, treat patients with intravenous morphine sulfate. This reduces the force of cardiac contraction and the rate of rise of the aortic pressure. It then retards the propagation of the dissection and delays rupture.
Antihypertensives, Other
Class Summary
These agents are used to reduce arterial dP/dt. For acute reduction of arterial pressure, the potent vasodilator sodium nitroprusside is effective. To reduce dP/dt acutely, administer an IV beta-blocker in incremental doses until a heart rate of 60-80 beats/min is attained.
When beta-blockers are contraindicated, such as in second- or third-degree atrioventricular block, consider using calcium channel blockers. Sublingual nifedipine successfully treats refractory hypertension associated with aortic dissection.
Esmolol (Brevibloc)
Esmolol is an ultra–short-acting beta1-blocker. It is particularly useful in patients with labile arterial pressure, especially if surgery is planned, because it can be discontinued abruptly if necessary. This agent is normally used in conjunction with nitroprusside. It may be useful as a means to test beta-blocker safety and tolerance in patients with a history of obstructive pulmonary disease who are at possible risk of bronchospasm from beta-blockade. The elimination half-life of esmolol is 9 minutes.
Labetalol (Trandate)
Labetalol blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure.
Propranolol (Inderal LA, InnoPran XL, Inderal XL, Hemangeol)
Propranolol is a class II antiarrhythmic nonselective beta-adrenergic receptor blocker. It has membrane-stabilizing activity and decreases the automaticity of contractions. Propranolol is not suitable for emergency treatment of hypertension. Do not administer propranolol IV in hypertensive emergencies.
Metoprolol (Lopressor, Toprol XL)
Metoprolol is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. During IV administration, carefully monitor the blood pressure, heart rate, and electrocardiogram (ECG). When considering conversion from IV to oral (PO) dosage forms, use the ratio of 1 mg IV to 2.5 mg PO metoprolol.
Nitroprusside (Nitropress)
Nitroprusside causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. It is commonly given intravenously because of its rapid onset and short duration of action. It is easily titratable to reach the desired effect.
Nitroprusside is light sensitive; both bottle and tubing should be wrapped in aluminum foil. Before initiating nitroprusside, administer a beta-blocker to counteract the physiologic response of reflex tachycardia that occurs when nitroprusside is used alone. This physiologic response increases shear forces against the aortic wall, thus increasing dP/dt. The objective is to keep the heart rate at 60-80 bpm.
Nifedipine (Procardia, Procardia XL, Adalat CC, Nifediac CC, Afeditab)
Nifedipine is one of the more common channel blockers used for hypertension.
Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and prevents exacerbations of tachycardia and hypertension.
Morphine sulfate (Astramorph, Infumorph, MS Contin, Avinza, Kadian)
Morphine is the drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Like fentanyl, morphine sulfate is easily titrated to the desired level of pain control. If administered IV, morphine may be dosed in a number of ways; it is commonly titrated until the desired effect is obtained.
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Aortic dissection. CT scan showing a flap (right side of image).
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Aortic dissection. True lumen versus false lumen in an intimal flap.
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Aortic dissection. Left subsegmental atelectasis and left pleural effusion. Flap at lower right of image.
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Aortic dissection. Significant left pleural effusion.
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Aortic dissection. CT scan showing a flap (center of image).
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Aortic dissection. CT scan showing a flap (center of image).
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Mediastinal widening.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Thrombus and a patent lumen.
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Aortic dissection. Thrombus.
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Aortic dissection. True lumen and false lumen separated by an intimal flap.
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Aortic dissection. Mediastinal widening.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Intimal flap and left pleural effusion.
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Image A represents a Stanford A or a DeBakey type 1 dissection. Image B represents a Stanford A or DeBakey type II dissection. Image C represents a Stanford type B or a DeBakey type III dissection. Image D is classified in a manner similar to A but contains an additional entry tear in the descending thoracic aorta. Note that a primary arch dissection does not fit neatly into either classification.
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Aortic dissection.
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Chest radiograph of a patient with aortic dissection. Image courtesy of Dr. K. London, University of California at Davis Medical Center.
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Chest radiograph of a patient with aortic dissection presenting with hemothorax.
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Chest radiograph demonstrating widened mediastinum in a patient with aortic dissection.
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Angiogram demonstrating dissection of the aorta in a patient with aortic dissection presenting with hemothorax.
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Electrocardiogram of a patient presenting to the ED with chest pain; this patient was diagnosed with aortic dissection.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
