EMERGENCY...

A 65 years old man with a history of hypertension presents with tearing chest pain that radiates to his back. he undergoes a CT scan that demostrates a descending aortic dissection originating just distal to the aortic arch and extending to the aortic bifurcation. no significant vascular obstruction is seen. the most appropriate initial therapy for this paitent should include:
a-thrombolytic therapy.
b-heparin.
c.emergant surgical intervention.
d.labetulol and nitroprusside.
e.IV fluids and narcotic analgesics.

Hi Ahmed : thank u for this interested case…note that:
1. All patients with aortic dissection should be treated with beta blocker to decrease the rate of pressure development within the aorta (even if they are normotensive).
2. As the dissection involves the descending part of aorta without complications (like vascular obstruction)…so there is no need for emergent surgical intervention as it may be treated medically.
The indications for emergent surgery are:
1. acute ascending aortic dissection.
2. any dissection in Marfan's syndrome.
3. Distal dissection complicated by:
A. Vascular compromise.
B. Aortic aneurism.
C. Rupture or impending rupture.
D. Retrograde propagation to the ascending aorta.
So the most appropriate initial therapy for this patient is :
Labetalol & Na Nitroprusside….but is recommended that we give the labetolol before Nitroprusside as the vasodilation that is associated with the later can results in reflex sympathetic activation with enhanced contractility & increase shear stress.
CT scan is repeated every 6 month……so extending or complicated dissection &/or poorly controlled with medications, in that time surgical intervention is must.

thanks dear for this amazing answer, it is correct and i have nothing to add, but would please write the resource for every answer in this forum, as i do..and thanks for ur great participation....

Hi doctors,
really nice case , and really nice answer

ahmed ...mohamed...u r the hero of this site.