1. SHORT CASEkritKuruchaiyapanich R2 5 hospital conference : 1st @ Rajavithi hospital 17 June 2010

2. History An elderly Thai female 80 years old Chief complaint: Progressive dyspnea for 2 weeks

3. 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.

4. History (con’t) Present illness - 2 weeks ago, she was progressive dyspnea on exertion, no chest pain, +ve PND, no orthopnea no back pain, no fever, no dizziness

5. 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

6. 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

7. 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

8. Investigation (31/5/2010)

9. Investigation (31/5/2010)

12. Ultrasound bedside

14. 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

15. CT Plain

17. 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.

18. Diagnosis Type B dissecting aneurysm of the descending aorta with hemorrhagic pericardial effusion

19. Treatment At ER O2 canula 3 LPM Closed up monitor vital signs Echocardigram searched for cardiac temponade NPO 0.9% NaCl 1,000 ml sig IV drip in 40 ml/hr Emergency CT whole aorta

20. Aortic disection

21. 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

22. 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

23. Classification

24. Management Airway, Breathing, Circulation Blood 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

25. 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

26. 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

27. 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

28. 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

29. Interventional Therapy Stent-graft and fenestration technique for complicated type B dissections Rosen’s Emergency medicine: Concepts and Clinical Practice, 6th Edition

30. THANK YOU