Aortic dissection – treatment in ED

Early therapy for aortic dissection is CRITICAL and should be started while waiting for imaging.

Treatment has 3 goals:

1. analgesia
2. reduce BP
3. reduce the rate of rise in arterial pulse to reduce vascular wall shearing forces i.e.reduce HR

Reduce BP / HR – target systolic BP 100-120 mmHg and HR < 60/min

A beta-blocker should be started before any vasodilators (to prevent the reflex tachycardia associated with vasodilators) – textbooks advise esmolol or labetalol but you can use metoprolol as well (selective Bblocker, so safe in patients with airway disease). If Bblockers are absolutely contraindicated, you can use a Calcium -channel blocker BUT a central-acting one (verapamil, diltiazem) and not a peripheral acting one (nifedipine, amlodipine)
Then start a vasodilator – nitroprusside or GTN.
If there is a BP difference between the 2 arms, treatment should be titrated to the higher BP, as they can get pseudohypotension due to an intimal flap obstructing the extremity.

If the patients are hypotensive, they should be fluid / blood resuscitated, but aim for sBP of 100mmHg, not higher. Pericardiocentesis can be a temporizing measure in the severely hypotensive patient, while awaiting transfer to theatre.

Type A aortic dissections (involving ascending aorta) require surgical treatment.
Type B aortic dissections (involving descending aorta only) can be managed medically in a tertiary hospital environment, with surgery only for those with ongoing pain, uncontrolled hypertension, occlusion of a major arterial trunk, rupture, or development of a localized aneurysm.