Case of the Month #30 Aortic Dissection
What are the goals of initial management for this gentleman?
For all cases of dissection the aim of initial medical management is to limit the potential for worsening end-organ damage and to prevent rupture (5). The main goals of treatment include pain management and haemodynamic control.
- Assess ABC. If the patient is has a GCS of less than 8 or is unable to maintain adequate oxygenation, consider airway protection with intubation and ventilation. Commence oxygen therapy.
- Optimise cardiovascular status; Circulatory targets should be a pulse of 60 BPM and a BP of between 100-120mmHg systolic (1). If hypertensive, this should be achieved with beta blockade; propranolol, metoprolol, labetolol, or esmolol are first line choices. Sodium Nitroprusside vasodilation can be used but only after beta blockade to avoid reflex tachycardia and inotropy. If beta blocker intolerant, non-dyhydropyridine calcium channel blockers are a suitable alternative (5).
- If haemodynamically unstable, resuscitate with balanced crystalloid or blood products as required. Consider the use of vasopressors.
- Analgesia can be achieved using the WHO pain ladder including opioids.
Despite medical management with oxygen, fluids, beta blockade and analgesia, the patient remains in significant pain and is persistently hypertensive.