Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection

Schuur, Jeremiah D.; Cantrill, Stephen V.; Brown, Michael D.; Burton, John H.; Diercks, Deborah B.; Gemme, Seth R.; Gerardo, Charles J.; Godwin, Steven A.; Hahn, Sigrid A.; Haukoos, Jason S.; Huff, J. Stephen; Lo, Bruce M.; Mace, Sharon E.; Moon, Michael D.; Nazarian, Devorah J.; Promes, Susan B.; Shah, Kaushal; Shih, Richard D.; Silvers, Scott M.; Smith, Michael D.; Tomaszewski, Christian; Valente, Jonathan H.; Wolf, Stephen J.; O’Connor, Robert E.; Whitson, Rhonda R.

doi:10.1016/j.annemergmed.2014.11.002

Cited by 66 publications

(66 citation statements)

References 52 publications

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“…We assigned levels of evidence (LOE) and graded our recommendations based on the American College of Emergency Physicians (ACEP) process of creating their clinical policies with slight modification to better fit our objectives 11. This committee of EMDAC reviewed studies and assigned LOEs based on the study design, including features such as data collection methods, randomization, blinding, outcome measures and generalizability.…”

Section: Methodsmentioning

confidence: 99%

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

Silverman¹,

Sporer²,

Lemieux³

et al. 2017

WestJEM

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IntroductionWe sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California.MethodsWe performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately.ResultsProtocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered.ConclusionProtocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.

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Section: Methodsmentioning

confidence: 99%

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

Silverman¹,

Sporer²,

Lemieux³

et al. 2017

WestJEM

View full text Add to dashboard Cite

show abstract

“…Differential systolic blood pressure higher than 20 mmHg in both arms had been determined as an independent predictor of the presence of acute aortic syndrome, but some recent studies have reported this condition as a normal finding in patients without this diagnosis (9). In this case, high pressure values were seen in all four limbs and with very different data between the two lower limbs, which helped increase the suspicion of the diagnosis.…”

Section: Discussionmentioning

confidence: 64%

“…The presentation of hypertension in the emergency department can be found in 45% of patients (8) and abdominal and back pain have been previously reported as more frequent in patients with type B AAD (1,7,9).…”

Section: Discussionmentioning

confidence: 99%

“…The cause of this situation is related to hypoperfusion and strokes when the renal arteries (7) are involved, which often requires additional studies to establish the AAD diagnosis. As to chest CT with aorta protocol, sensitivity of 99% and specificity 00% for this diagnosis was found (9). Similarly, determining the role of markers such as D-dimer, which, with a negative value in a low-risk patient, helps to exclude the diagnosis (11) has been attempted.…”

Section: Discussionmentioning

confidence: 99%

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Bilateral testicular pain as an acute aortic dissection symptom

2016

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CASE REPORT | Abstract |Acute aortic dissection is a serious cardiovascular event and the most common acute disease of the great vessels. According to the anatomical distribution of the compromised aorta, the Stanford Group classifies it into type A and type B. Its prognosis depends on its early identification and treatment, as the mortality rate in type A increases rapidly with each hour of delay of diagnosis.Clinical manifestations of aortic dissection may be varied, which makes its early diagnosis difficult. Regarding its diagnosis, genital pain is one of the rarest symptoms. In this paper, the case of a patient who initially attended a health care institution due to acute bilateral testicular pain and was eventually diagnosed with acute aortic dissection is presented. | Resumen |La disección aórtica aguda es un evento cardiovascular catastrófico que corresponde a la más común de las enfermedades agudas de los grandes vasos. Según la distribución anatómica de la aorta comprometida, el grupo de Stanford la clasifica en dos tipos: A y B. Su pronóstico depende de la identificación y manejo tempranos, siendo la tasa de mortalidad rápidamente creciente en el tipo A con cada hora que se retrasa el diagnóstico.Las manifestaciones clínicas de la disección aórtica pueden ser múltiples, lo que dificulta su diagnóstico precoz. Dentro de las formas de presentación, una de las más infrecuentes es el dolor en los genitales. Se presenta el caso clínico de un paciente que consulta inicialmente por un dolor agudo testicular bilateral y que finalmente es diagnosticado con disección aórtica aguda.

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“…In such cases attempts must be done to stabilize the patient with medical therapy which includes volume expansion with crystalloids and vasopressors (norepinephrine and phenylephrine) to titrate the mean arterial pressure at 70 mmHg. The extreme aggressive attempts at doing so may result in further propagation of false lumen [78] with adverse outcome, the aortic insufficiency and pericardial tamponade since both conditions are preload-dependent [79]. Therefore, treatment of shock associated with aortic dissection should be managed by rapid surgical intervention.…”

Section: Medical Therapymentioning

confidence: 99%

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

Muthiah¹

2017

CRCM

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Aim: To present a rare occurrence of aortopulmonary fistula due to rupture of proximal aortic dissection in a 48-year-old woman. Introduction: Aortic dissection is defined as disruption of the medial layer provoked by intramural bleeding, resulting in separation of aortic wall layers and subsequent formation of a true lumen and a false lumen with or without communication. Case Report: A 48-year-old female presented with vague anterior chest discomfort, high blood pressure, systolic-diastolic murmur in the left sternal border with ECG changes of myocardial ischemia. Echocardiography revealed a dilated aortic root with intimal flaps, a leak into the pulmonary artery and regional hypokinesis with contractile dysfunction suggesting a proximal aortic dissection with rupture into the main pulmonary artery. Discussion: The etiology of aortic dissection was mostly hypertension in 80% of cases and aortopathies such as connective tissue disorders, inflammatory and idiopathic. Aortic wall stress is a major trigger of intimal tear and two-dimensional transthoracic echocardiography is an excellent, initial diagnostic gold standard to detect the dissecting flaps, especially in proximal aortic dissection. Conclusion: Blood pressure control is the mainstay of treatment and urgent surgery is indicated in proximal aortic dissection since there is higher chance of rupture with an increase in mortality.

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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection

Cited by 66 publications

References 52 publications

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

Bilateral testicular pain as an acute aortic dissection symptom

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

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