Cardiology | Monash SAQ 2022.1 Q11

​​Brain Food is a project to drip feed clinical knowledge (in the form of mock SAQs) to satisfy those hungry neurons. Sources are SA/NT Trial Exam 2021.2 and Monash 2022.1. Answers are prone to ageing. Leave a comment if you don't understand or something doesn't seem right...
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A 78YO man presents with tearing chest pain suggestive of aortic dissection. 

1. Complete the following table (CT aortagram v. TTE), by listing two pros and two cons, regarding the utility of the following investigations in the diagnosis and management of aortic dissection. (8 marks)

Modality	Pro	Con
CT aortagram	Answer here ​	Answer here  ​
TTE	Answer here ​	Answer here  ​

Modality	Pro	Con
CT aortagram	localises site identified branch artery involvement  rupture with end organ involvement (sens 100%, spec 100%	can't assess aortic incompetence patient requires transport away from resus
TTE	sensitive for ascending aorta involvement excellent to assess valve involvement and tamponade	unable to visualise descending aorta operator variability

2. List two principles of blood pressure management when treating aortic dissection

• Time critical nature
• Prevent reflex tachycardia (prevent shear forces on flap)
• Vasodilators much follow rate control
• Invasive BP monitoring required
• Infusions required to carefully control BP
• Set HR and BP goals early; SBP 120-130, HR <60

3. State two (2) key issues with management of a patient with proven Type A aortic dissection in addition to blood pressure management. (2 marks)

• Analgesia, e.g. titrated IV morphine will help with BP control
• Early cardiothoracic surgical referral, if untreated death rate is 1% per hour. 
• Early transfer, communications for definitive care
• Establish Rx aims/limitations
• Definitive treatment is urgent to minimise morbidity and mortality 
• Avoid pericardiocentesis and inotropes if possible.