Acute Aortic Syndromes Discussion Solutions

Acute Aortic Syndromes Discussion Solutions
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Acute Aortic Syndromes Discussion Solutions
1. A 75-year-old male with hypertension and coronary artery
disease suddenly develops back and chest discomfort
and shortness of breath. Emergency medical services are
summoned. On arrival, the patient is found unresponsive
with a systolic blood pressure of 75 mm Hg. Upon arrival
at the emergency department, an electrocardiogram is
performed that indicates an acute inferior myocardial
infarction. Soon thereafter, the patient develops a cardiac
arrest and expires. Echocardiography is performed during
the resuscitation attempt. The images in Figure 47.1 are
obtained.
Which of the following answers best explains this scenario?
A. An acute inferior myocardial infarction with rupture
of the coronary artery into the pericardial space
B. An acute inferior myocardial infarction followed by
rupture of the ventricular free wall into the pericardial
space
C. Myocardial tamponade due to a malignant pericardial
effusion with associated myocardial ischemia from
hypotension
D. Acute aortic dissection with extension to the aortic
root and hemorrhage into the pericardium
E. Purulent pericarditis with the development of
myocardial ischemia due to hypotension
Chapter 47
Acute Aortic Syndromes
Charles L. Campbell
Figure 47.1 Bedside transthoracic images of a 75-year-old male with chest pain and shock.
(c) 2015 Wolters Kluwer. All Rights Reserved.
398 Section XI Aorta
2. A 48-year-old male presents to the emergency department with abdominal pain. He has a history of hypertension and coronary artery disease and an aortic valve
replacement. Recently, he has noticed difculty walking long distances due to thigh pain. In the emergency
department, the patient is noted to be in moderate
distress. His heart rate is 103 bpm, and blood pressure is
found to be 190/70 mm Hg, and he has normal oxygen
saturations. He has moderate abdominal tenderness on
examination with a normal cardiac exam. An electrocardiogram is performed showing sinus tachycardia. A chest
x-ray shows a slightly widened mediastinum and a small
left pleural effusion. His initial laboratory values show a
serum creatinine level of 1.1 mg/dL. While waiting for a
computed tomographic study to be performed, a transthoracic echocardiogram is performed. The images in
Figure 47.2 are obtained.
Which of the following statements describes the scenario and
a reasonable “next step” in the management of the patient?
A. A type B dissection is suspected. Medical therapy with
a beta-blocker is indicated, and a surgical intervention
is unlikely to be of benet.
B. A type A dissection is noted. Immediate consultation
with a thoracic surgeon is recommended, and transfer
to the operating room for surgical repair is indicated.
C. An aortic dissection is noted, and the extent is
unknown. A surgical intervention is eminent. Transfer
to the operating room following the initiation of
medical therapy is recommended with intraoperative
transesophageal echocardiography employed to
determine the extent of the dissection.
D. An aortic dissection is noted. Initiation of
medical therapy with sodium nitroprusside is
reasonable, followed by emergent transesophageal
echocardiography to determine the extent of the
dissection.
E. An aortic dissection in the descending aorta is noted.
The initiation of medical therapy with a beta-blocker
and sodium nitroprusside is reasonable followed
by the use of computed tomography, or magnetic
resonance imaging to determine the extent of the
dissection is warranted
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