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Cardiology Corner: Aortic Dissection

Amal Mattu, MD FAAEM and Anand Swaminathan, MD FAAEM
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22:21
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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02:34

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EMRAP 2019 01 January Written Summary 302 KB - PDF

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Steve D. -

Another mechanism for hypotension is retrograde dissection into the coronary arteries leading to cardiogenic shock

Joseph B. -

Agree with the above comment by Steve D. I commonly hear discussion about bedside echo to look for tamponade in dissection. The absence of tamponade should not give any assurance a type A dissection is not present.

The fixation of POCUS/TTE on effusion is an overly simplistic cognitive framework here. There are a plethora of other findings we should look for - aortic insufficiency, dilation of the aortic root, dissection flap in ascending/descending thoracic aorta or abdominal aorta, and so on. The sensitivity of TTE for type A dissection in an expert sonographers hands is >80%. Given the incredibly challenging clinical diagnosis, adding to our diagnostic toolkit is prudent. With this said, if our clinical suspicion is high enough to warrant CT-a, we should not let our bedside echo delay a scan.

To the comment that an effusion is something we can do something about - pericardiocentesis here is associated with extremely high mortality and if the patient has not arrested I would favour getting the patient to the OR stat, rather than stay/play.

I am an EP, and a cardiac surgical intensivist. I have a unique vantage point of looking at Type A presentations through the retrospectiscope. The diagnosis is no doubt extremely challenging (Yes, I have missed dissections myself). However, I do often see patients with at least one or two "classic" features that get missed. Frequently this is the sudden onset of pain (but not necessarily severe), and the presence of a new murmur. Great job Amal and Anand for emphasizing these features in the 'cast. We need to keep talking about dissection, sharing stories amongst ourselves of cases we caught and cases we missed, because patients will never read the (whole) textbook.

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EM:RAP 2019 January Full episode audio for MD edition 226:18 min - 211 MB - M4AEM:RAP 2019 January German Edition Deutsche 103:05 min - 142 MB - MP3EM:RAP 2019 January Canadian Edition Canadian 27:18 min - 38 MB - MP3EM:RAP 2019 January Spanish Edition Español 80:39 min - 111 MB - MP3EM:RAP 2019 French Edition Français 20:32 min - 28 MB - MP3EM:RAP 2019 January Aussie Edition Australian 0:44 min - 1 MB - MP3EMRAP 2019 01 January Board Review Answers 125 KB - PDFEMRAP 2019 01 January Board Review Questions 302 KB - PDFEMRAP 2019 01 January Individual Written 655 KB - ZIPEMRAP 2019 01 January Written Summary 302 KB - PDFEM:RAP 2019 January Individual MP3 Files 204 MB - ZIPEM:RAP 2019 January Spanish Written 803 KB - PDF

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