Has anyone treated a...

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CWATT

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...aortic dissection (thorasic or abdominal)?

If so, what was your treatment plan, and did you provide pain management? My protocols call for Fentanyl in hypotensive pt's and I'm wondering if the symptomatic pain relief in combination with the nature of the opiate had any effect on reducing C/O, thus slowing the dissection?


- C
 
Had one yesterday. The goal is to reduce shearing forces on the aorta by reducing heart rate and blood pressure. Our protocols are for SBP < 100 and HR < 60. Beta blockers are first line treatment with Labetalol or Esmolol drip and then a Nipride drip added if needed. And then of course analgesia and anxiolysis helps with reducing sympathetic tone.
 
I remember one specifically pretty well, though it's been a while. Dissecting abdominal and thoracic aneurysms being transferred for immediate surgery. The goals were in line with Chase's post- labetolol infusion titrated to maintain SBP below 120 (per transferring physician) with morphine boluses prn for pain (the system I was with didn't have fent or versed at the time).
 
Since you are not going to be controlling BP prehospital, your focus should be on pain control. That can certainly help with the BP as well.
Really the most important thing that we paramedics can do is to recognize that our patient may be having a dissection or aneurysm, and then calling to find out which hospital will be most appropriate for taking care of the patient. Just showing up at a ten-bed ER may result in the patient having a bad outcome.
 
CWATT said:
...aortic dissection (thorasic or abdominal)?

If so, what was your treatment plan, and did you provide pain management? My protocols call for Fentanyl in hypotensive pt's and I'm wondering if the symptomatic pain relief in combination with the nature of the opiate had any effect on reducing C/O, thus slowing the dissection?


- C
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When i did my hospital rotations we had an awesome type I aortic dissection. Long story short- a 50ish years old obese woman, week after normal vaginal birth. Presented to the ed by a bls crew with a complaint of sob. Initally she seemed fine.
I was taking her vitals and preparing to get and iv and blood work then she crashed.(lost consciousness and peripheral pulse). In the resus bay she was very hypotensive, a echo showed a large tamponde. We gave her fluids and started a dopamine drip cardiologist performed a transesophagal us which showed ascending aortic dissection. Treated surgically and discharged a few days later.

On the rig i had another one, 40 yom usually healthy with retrostrenal chest pain,looks pretty sick pale and diaphoretic. ECG showed relative sinus bradycardia and non specific st t changes.
Suspecting right ventricular mi he recived asa and morphine.
Ended up being another ascending aorta dissection, the dissection started from the aortic sinus, blocking the right aortic sinus exit. Which is probably why the presentation seemed like rv mi.
Guess what im trying to say is you may not be able to provide deifjnite care for the dissection itself but you sure can treat the symptoms and secondary pathologies caused by it.

Sorry for any spelling errors, wrote it from my phone.
 
I've taken this patient to the hospital from the street and I've transferred this patient from the inappropriately selected community hospital to the tertiary care facility capable of treating their problem.

Nothing really to add to what's been said. Keep their pressure down, keep them calm and keep them from flopping around the stretcher like a landed tuna. Anything you do that keeps their pressure high enough to perfuse, but low enough to no cause or exacerbate bleeding is probably a good idea.

I carry morphine and fent for analgesia. The only BB I have is metoprolol and my state prohibits me from accepting off list medications from the sending facility for the purpose of bolus administration during transport; so any other meds have to be infused.
 
Eden said:
When i did my hospital rotations we had an awesome type I aortic dissection. Long story short- a 50ish years old obese woman, week after normal vaginal birth. Presented to the ed by a bls crew with a complaint of sob. Initally she seemed fine.
I was taking her vitals and preparing to get and iv and blood work then she crashed.(lost consciousness and peripheral pulse). In the resus bay she was very hypotensive, a echo showed a large tamponde. We gave her fluids and started a dopamine drip cardiologist performed a transesophagal us which showed ascending aortic dissection. Treated surgically and discharged a few days later.

On the rig i had another one, 40 yom usually healthy with retrostrenal chest pain,looks pretty sick pale and diaphoretic. ECG showed relative sinus bradycardia and non specific st t changes.
Suspecting right ventricular mi he recived asa and morphine.
Ended up being another ascending aorta dissection, the dissection started from the aortic sinus, blocking the right aortic sinus exit. Which is probably why the presentation seemed like rv mi.
Guess what im trying to say is you may not be able to provide deifjnite care for the dissection itself but you sure can treat the symptoms and secondary pathologies caused by it.

Sorry for any spelling errors, wrote it from my phone.
Click to expand...

This is an important learning point. When you disect into a coronary, any of them, blood flow is severely compromised to the associated myocardium. And frequently these patients infarct some of their muscle before flow can be surgically restored.

They often present with crushing chest pain, both from the dissection and the associated ischemia/infarct if a coronary has been compromised. And, of course most protocols would dictate that a patient with crushing chest pain and myocardial ischemia on ekg should receive prehospital nitroglycerin. Which is a bit of a conundrum because nitro can cause tachycardia, producing a large amount of shear force, as mentioned above.
 
Generally speaking, aortic dissections are in the chest, aortic rupture is in the abdomen. As rare as aortic dissections are, they can be very tricky to diagnose. Just took care of one that was sent home from the ER before being flown to the Mothership for surgical repair.

Ruptured abdominal aneurysms present differently and can go to some hospitals that dissections can't because cardiopulmonary bypass/ CT surgeons aren't required for their repair. Bottom line is that field diagnosis is pretty difficult for both, and symptomatic treatment is all you can do. Either way, a MAP of 70-75 is ideal if you can swing it.
 
Esmolol seems to be the B-blocker of choice here in regards to the few I've transferred out.
I'm always a little hinky about moving them, and the last one I could remember the ED techs and RN's sort of scoffed at me when I asked for an all hands on deck approach moving them from their bed to our gurney. A 3 plus hour ground leg with that sort of acuity seems worthy of an ever so cautious approach.
E tank said:
a MAP of 70-75 is ideal if you can swing it.
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This is good general street paramedic knowledge to know, so I thanks tank.

Aside from that, judicious Fent boluses for pain, a couple of large bore IV's if time permits, and a quick trip to the more capable ED's we have.

One of my favorite instructors thus far encouraged even attaching 1, if not both, lines to NS bags fully primed, and prepped in case it ruptures en route that way they're ready to infuse.
 
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If you are looking at a 3hr ground transport then I would not leave that hospital with out 2 units of blood in a cooler, that NS isn't going to do much. But I agree have a pressure line hooked up and ready to go.
 
Chase said:
If you are looking at a 3hr ground transport then I would not leave that hospital with out 2 units of blood in a cooler, that NS isn't going to do much. But I agree have a pressure line hooked up and ready to go.
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This was an IFT already vented, receiving Esmolol and the remaining standard formulary.

I was referring to the out of hospital scene calls at the most rudimentary prehospital paramedic level. Plus, we don't carry blood products unless it's already been established and infused/ infusing when we get there.
 
VentMonkey said:
This was an IFT already vented, receiving Esmolol and the remaining standard formulary.

I was referring to the out of hospital scene calls at the most rudimentary prehospital paramedic level. Plus, we don't carry blood products unless it's already been established and infused/ infusing when we get there.
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Your nurse can't initiate it if the sending sends it with an order?


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Handsome Robb said:
Your nurse can't initiate it if the sending sends it with an order?
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Yes, they absolutely can. Lol, again the post was half rant/ half basic ALS paramedic treatment.

I'm trying to keep it relevant to all levels of provider here:).
 
Yep, I had one not too long ago.

Focus on treating not only pain but nausea as well, since heaving is not the best thing for a dissecting patient to do.

We can then either use Labetalol 20 mg q 10 min doubling each subsequent dose to max of 300 mg, or Cardene 5 mg/hr, titrated up by 2.5 mg/hr q 5-10 min. Our target is a SBP 80-100 and/or HR ~60.
 
On a side note I have seen providers be very conservative and a little leery of aggressive blood pressure management in these patients in fear of "bottoming out". Just like in the hemorrhagic trauma patient permissive hypotension is the way to go if they are actively dissecting. Chances are they have multiple major arteries (mesenteric, renal, etc) arising from the false lumen and being poorly perfused if at all anyway, that SBP of 80 isn't going to hurt them.
 
Chase said:
On a side note I have seen providers be very conservative and a little leery of aggressive blood pressure management in these patients in fear of "bottoming out". Just like in the hemorrhagic trauma patient permissive hypotension is the way to go if they are actively dissecting. Chances are they have multiple major arteries (mesenteric, renal, etc) arising from the false lumen and being poorly perfused if at all anyway, that SBP of 80 isn't going to hurt them.
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Probably due to a lack of clinical history with blood pressure management by medics. Since it's engrained in our heads that every time you treat blood pressure pre-hospital a puppy is murdered, many providers are conservative with doing so.
 
Chase said:
On a side note I have seen providers be very conservative and a little leery of aggressive blood pressure management in these patients in fear of "bottoming out". Just like in the hemorrhagic trauma patient permissive hypotension is the way to go if they are actively dissecting. Chances are they have multiple major arteries (mesenteric, renal, etc) arising from the false lumen and being poorly perfused if at all anyway, that SBP of 80 isn't going to hurt them.
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Or go the other way by slam dunking blood/crystalloid with a perfect blood pressure of 85/40...docs, RN's or medics. And don't get me started about all the NS the patient has had...but that's a different thread.
 
I think a good strategy in these patients is generous fentanyl with cardizem on top.

If you get their hemodynamics where you want them with Ca or Beta blockers, and THEN try to provide analgesia, you might end up bouncing their BP down and up more than you'd like to as you adjust the drips.
 
I've taken several. But being that it was LA County, we just drove slow very quickly.

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