Aortic Dissection

[Hockey]

Anyone ever deal with this?


I'll explain later but just want to see if anyone has ever had a patient with this going on? Survival?

 

[Hockey]

Hanging out at the ER doing coverage and PT came in w/ CP and back pain. Pt was cynatoic nipple line up. Never saw that before so I decided to follow around and see what was going on. I figured PE and so did a few other people. Pt's back was cynatoic too.

They determined PT was having a Dissecting Aortic Aneurysm (or Aortic Dissection or whatever you want to call it). Mind you this is a small town hospital so anything major gets moved. 2 hours later they finally determine that no helicopter or fixed wing plane is coming to town to get this PT. Its raining, but IFR would be fine. Not that bad out (even my partner used to work on the chopper for 10+ years said that).

Fine, so we figure take PT to nearest hospital 1½ hours away to the hospital. Nope. No room, not the right people, and who else knows "why". So they finally determine, we are heading to one of the best hospitals in the state, 138 miles south. Nobody expected the PT to survive the trip down there including me. We asked for helicopter intercept at an airport that we'd be passing, and still nothing. Don't ask, I haven't got a clue.

So off we go hot on our long trip. They gave us a unit of blood which even if myself or the paramedic could give it, what good is just one unit of blood going to do. (3 of us on the rig). I watched the monitor all the way down there really expecting for the PT to crash. It was interesting watching when the PT would readjust themself and you could see their back being purple, and it would go from the entire half both sides being purple, to it flowing to the lower half and pooling there. (The gravity pulling the blood from inside the PT to the lower side). That I have NEVER seen before nor my partner.

Got the PT into the ER and let the team take over from there. Vitals stayed stable the entire trip down there.

Definitely a new experience. Poor PT though. Scary how this stuff can just come on out of no where...

By the way, for those who don't know, this is what killed John Ritter

 

[Melclin]

Couldn't have been much of a dissection. Have you seen the aorta bleed? Like in a surgery video or perhaps in a trauma case? The thing shoots like a garden hose without the nozle attached.

Can anyone explain if there are different degrees of AAA's? The must be something like that. With a full dissection a pt. live expectancy can be measured in seconds, yet I hear stories like Hockey9019's. Even if the hemorrhage is small I wouldn't have thought a pt would live that long.

 

[Foxbat]

If I remember correctly, dissecting aneurism is basically creation of a false lumen between layers of aortic wall. Not all of them rupture... necessarily.

 

[Melclin]

ah, yeah that makes sense. Should have just wiki'ed it. Very clear explanation there.

 

[CAOX3]

The guy was cyanotic from the nipples up and was still alive? Ive never seen that.

A dissection can cross all three layers of the aortic wall, also depends on if its in the ascending aorta or the descending aorta. (type A or b)

 

[Ridryder911]

There are many different types of dissections of any type of vessels. Up to about 15 years ago the morbidity rate was about >95% but now with new surgical techniques such as the "sleeve" we have seen a major reduction and increasing survivability rate.

I have assisted in the O.R. on such cases as they ruptured and no it is not a pretty site.

R/r 911

 

[MSDeltaFlt]

There are many different types of dissections of any type of vessels. Up to about 15 years ago the morbidity rate was about >95% but now with new surgical techniques such as the "sleeve" we have seen a major reduction and increasing survivability rate.

I have assisted in the O.R. on such cases as they ruptured and no it is not a pretty site.

R/r 911

Flew a guy once with a comlete dissection from the Aortic Arch to below the Femoral bifercations. He made it to surgery, but not afterwards.

 

[Melclin]

Flew a guy once with a comlete dissection from the Aortic Arch to below the Femoral bifercations.

Woah.......

 

[Hockey]

The guy was cyanotic from the nipples up and was still alive? Ive never seen that.

A dissection can cross all three layers of the aortic wall, also depends on if its in the ascending aorta or the descending aorta. (type A or b)

Me neither.

I'm going back Friday so I'm going to try to find out what went down

 

[boingo]

Had a woman a few months back, hx cocaine use and HTN, sudden onset 10/10 cx pain, crying, wouldn't sit still. 170/100ish on the L arm, 90/60ish on the R, disected from the arch to her renal arteries, went to the OR, survived and d/c alive w/o deficits.

 

[Hockey]

Had a woman a few months back, hx cocaine use and HTN, sudden onset 10/10 cx pain, crying, wouldn't sit still. 170/100ish on the L arm, 90/60ish on the R, disected from the arch to her renal arteries, went to the OR, survived and d/c alive w/o deficits.

How long though before she hit the table?


My PT we're looking at LEAST 6 hours, and thats not counting how long at home

 

[DrankTheKoolaid]

re

Wow thats a lucky patient as not many survive once they do. Ive seen a few of em in the field and in the ED and have never noted them to be discolored from the nipple line up. I have seen it before on a cardiac tamponade and if memory serves its called vena cavae syndrome. Is usually related to an obstructive process. My guess is your patient had multiple problems going o. definately keep us updated!

 

[boingo]

How long though before she hit the table?


My PT we're looking at LEAST 6 hours, and thats not counting how long at home

Probably an hour or so. We called it in with our findings, 10 minutes on scene, 10 minute drive, spent about 15 minutes in the ED, off to CT and from there to the OR.

 

[Melclin]

If the aneurysm extended proximally (rare apparently) and/or ruptured into the pericardium it could cause cardiac tamponade.

These blokes reckon it can happen: Isselbacher EM, Cigarroa JE, Eagle KA (Nov 1994). "Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful?". Circulation 90 (5): 2375–8.

Seems like that could cause the nipple line discolouration (but prob not cyanosis) symptomatic of acute superior vena carva syndrome, good memory corky . But there'd also be oedema above the nipple line and neck vein distention. Am I talking out my arse here?

 

[DrankTheKoolaid]

re

Yeah i agree that you would think that JVD would be part of the natural progression of it. The guy that i had seen in the field we only found out later that is was a tamponade. Had a full blown transmural MI which created the tamponde. I dont recall any JVD though. But according to the guys mom on seen he went down fast after a violent coughing spell which i assume now was from the pulmonary congestion secondary to the Tamponade.

 

[Aidey]

My last code was a probable Aortic dissection, fairly high up. The guy was smurf blue from the nipples up, and pale pink from the nipples down. Witnessed arrest with CPR started immediately by a retired RN. Guy was asystolic by the time we got there about 8 to 10 minutes after the call. Doc in the ED took one look at him and declared him.

 

[Melclin]

My last code was a probable Aortic dissection, fairly high up. The guy was smurf blue from the nipples up, and pale pink from the nipples down. Witnessed arrest with CPR started immediately by a retired RN. Guy was asystolic by the time we got there about 8 to 10 minutes after the call. Doc in the ED took one look at him and declared him.

Why'd you take him to hospital? That raises an interesting question...do you transport all patients, even if they're dead? What guidelines/protocols do you have regarding ceasing resuscitation in the field?

 

[Aidey]

We did in that case because of a long combination of factors, some medical, situational, but we don't have to transport all patients.

 

[JonnyDMartin]

Free Aortic Dissection Resources Available

If you are interested, the National Marfan Foundation offers free educational resources created for emergency professionals about emergency diagnosis and treatment of aortic dissection, including resources specifically for EMS/EMT.

The packet includes a 55 minutes DVD on AD as well as a variety of supplementary materials.

People with Marfan syndrome are at up to 250x increased risk of AD than the general population.

Request a free set of the materials at marfan(dot)org. It's in Healthcare Professionals section of the website, under Toolkit.