Current management of type B aortic dissection Table 2 Approach to acute aortic dissections (AAD) in the emergency department 1) Have a high index of suspicion for AAD a) History: i) Sudden onset, severe, sharp or tearing back pain, chest pain, shoulder pain, or abdominal pain ii) Older than 60 years, history of hypertension, aortic dissection or aortic aneurysm (of family history of such), previous cardiac surgery, con- nective tissue disorder (Bicuspid aortic valve, Marfan syndrome, Ehler-Danlos syndrome, Loeys-Dietz syndrome), or peripartum b) Physical examination: (1) Pulse deﬁcit, blood pressure differential in various extremities (2) Neurological deﬁcits (3) Abdominal pain, ﬂank pain 2) General measures: a) Establish two large bore ( 18gauge) IV’s b) Administer supplemental oxygen by nasal cannula or nonrebreather mask c) Put patient on cardiac monitor d) Get an EKG, portable chest X-ray, place a Foley catheter e) Obtain CBC, chemistry panel, coagulation panel, UA, CK, Troponin, d-dimer f) Type and cross 10 units packed red blood cells (PRBC’s) g) Set up an arterial line 3) Early cardiothoracic surgical consultation 4) Deﬁnitive imaging: a) Computed tomography angiogram (CTA) b) Transesophageal echocardiogram c) Magnetic resonance angiogram (MRA) d) Intravascular ultrasound e) Aortography 5) Blood pressure, heart rate, and pain management a) First line: β-blockers i) Labetalol, bolus (15 mg) ± a drip (5 mg/hour), b) If hypertension persists, add: i) Nicardipine drip (starting dose: 5 mg/h) c) If tachycardia persists, add: i) Esmolol (loading 0.5 mg/kg over 2–5 min, followed by a drip of 10–20 μg/kg/min) ii) Diltiazem drip (loading 0.25 mg/kg over 2–5 min, followed by a drip of 5mg/h) d) Goals: (1) Heart rate 60 beats/min (2) Systolic blood pressure 100 mm Hg e) Morphine (for pain relief) 6) Hemodynamically unstable patients a) Tracheal intubation, mechanical ventilation b) Blood pressure support with crystalloid and colloid (PRBC’s if rupture is suspected) c) TEE at bedside in the Emergency Department or in the OR d) Pericardiocentesis is not recommended (class III) vasodilator without the reﬂex tachycardia (eg, nicardipine), can be added as second line drugs for refractory hypertension. β-blockers are the ﬁrst line drugs because they control the maximal force of left ventricular contraction (dP/dtmax) in addition to controlling HR and BP. This helps reduce further dissection, branch-vessel malperfusion and weakening of the aortic wall. Common β-blockers include labetalol, esmolol, metoprolol, and atenolol. Targeted HR and systolic BP should be 60 beats/min and 100 mm Hg, respectively. In patients with potential intolerance to β-blockers (eg, asthma, heart failure), a test dose of a short acting β-blocker such as esmolol should be tried.35 If β-blockers can not be used, calcium channel blockers (eg, nicardipine, clevidipine or diltiazem) might be alternatives to control blood pressure in these patients. Hydralazine and sodium nitroprusside have been used in the past for medical management of type B AAD. Although these agents reduce blood pressure, they increase the maximal force of left ventricular contraction (dP/dtmax) and cause reﬂex tachycardia and are, thus, con- traindicated in patients with AAD. Hemodynamically unstable patients with type B AAD are either in hemorrhagic shock or septic/metabolic shock from visceral or limb malperfusion. They should be endotracheally intubated and ﬂuid resuscitated with crystalloid, PRBC’s, or other colloid. In these patients, a TEE or CTA are the preferred diagnostic tools, depending on the hospital setting. Vascular Health and Risk Management 2009:5 61