Thoracic Aortic Aneurysm

You are the cardiothoracic surgery CT1 called to the emergency department to review a 64-year old builder with Marfan’s syndrome who was brought in by ambulance with sudden onset tearing chest pain unlike any he had experienced before. On examination they noticed the blood pressure in the left arm was 25mmHg less than in the right arm. The A&E doctor says they have performed an ECG, but it is normal. FAST scan show mild pericardial effusion. He is in ED resus in pain but haemodynamically stable.

You are shown a PA chest X-ray which demonstrates widening of the mediastinum. How would you manage this situation?

Example answer introduction

In this scenario I would be most worried about a thoracic aortic dissection. I would assess this patient using an A-E approach, take a focused history and perform a chest examination. I would contact the cardiothoracic surgical regestrar once I had put in place my initial management plan.

Initial Assessment and Simultaneous Resuscitation

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

Airway
Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
Circulation
- Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
- IV access - large bore and bloods including CRP
- Give fluid challenge of 250ml crystalloid solution if evidence of shock
- If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
Disability - GCS, pupillary response, blood sugar, temperature
Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Troponin I, clotting studies and Group and Save.

BE PREPARED TO JUSTIFY YOUR BLOOD TESTS

Focused history

Allergies
Medications
Past medical history including previous surgery – cardiac arrhythmia
Last meal
Events leading up to this point – time of onset, known history of a thoracic aortic aneurism.

I would attempt to determine whether this was an ascending or descending rupture from clues in the history and on examination.

Ascending - pain more in chest
Descending - pain more in back

Abdominal examination

Chest examination may help reveal signs of whether the aneurism is ascending or descending aorta:

Ascending - acute coronary syndrome, cardiac tamponade, hemothorax, focal neurologic deficits related to cerebrovascular ischemia, and upper extremity pulse deficit
Descending - lower extremity ischemia, and focal neurologic deficits related to spinal ischemia

ASK FOR A CHAPERONE

Initial management

You are presented with a CT scan of the chest confirming aortic dissection. What would your initial management be?

Inform the cardiothoracic registrar to IMMEDIATELY review the patient

Analgesia according to the WHO pain ladder
IV crystalloids to maintain urine output of 0.5ml/kg/hr - remember permissive hypotension
Keep nil-by-mouth
Prep for theatre - consent if able to, book theatre, anaesthetics, ICU
Keep patient and any relatives informed
Document, document, document!!!

Escalation

People who will be involved if the patient goes to theatre:

1. Aaesthetic consultant

2. ICU consultant

3. Vascular Regestrar and consultant

4. Haematology

5. Transfusion team

Useful Resources

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.