{"id":1918,"date":"2020-12-02T08:00:00","date_gmt":"2020-12-02T08:00:00","guid":{"rendered":"https:\/\/emultrasound.sdsc.edu\/?p=1918"},"modified":"2021-03-04T04:59:15","modified_gmt":"2021-03-04T04:59:15","slug":"aortic-dissection","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2020\/12\/02\/aortic-dissection\/","title":{"rendered":"Case 25: Aortic Dissection"},"content":{"rendered":"
\n
\n
\n
\n
\n

A 44 year old male with a history of heroin abuse presents to the emergency department with altered mental status.  Per EMS, the patient was found on the street with decreased level of consciousness and poor respiratory effort.  EMS was concerned about opioid overdose, and he was treated with 4mg Narcan, with improvement in his mental status.  <\/p>\n

Upon arrival to the ED, he was noted to be agitated and tachypneic with RR in the 40’s.  <\/p>\n

Vitals: BP 90\/65 mmHg, HR 110, O2 100% on RA, glucose 158.<\/p>\n

He is alert and oriented to person, month, and place, but appears agitated and confused.  He denies any complaints other than shortness of breath, and states he felt fine before using heroin.  He denies any past medical history.<\/p>\n

Exam notable for tachycardia, diffuse rhonchi throughout all lung fields, 2+ nonpitting lower extremity edema.  He is neurologically intact with 2+ pulses throughout.<\/p>\n

A bedside echocardiogram was performed, what do you see?  What are your next steps?<\/p>\n<\/div>\n<\/div>\n<\/div>\n

\n
\n
\"PS<\/div>\n<\/div>\n
\n
\"dilated<\/div>\n<\/div>\n<\/div>\n
\n
\n
\"aortic<\/div>\n<\/div>\n<\/div>\n
\n
\n
\"abdominal<\/div>\n<\/div>\n
\n
\"abdominal<\/div>\n<\/div>\n<\/div>\n
\n
\n
\"dissection<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n
\n
\n
\n

Answer and Learning Points<\/h3>
\n

Answer: <\/span><\/strong><\/p>\n

The first two images show a parasternal long-axis view, with a dilated aortic root measuring approximately 4.2cm.\u00a0 Also notice the pericardial effusion with a homogenous layer that appears fixed to the pericardium.\u00a0 At the time it was unclear whether this represented a clot within the pericardial sac, or was superficial to it.<\/span><\/p>\n

Given the dilated aortic root, a suprasternal short-axis view was obtained to assess the proximal aorta, with the short axis view seen on the third image.\u00a0 A flap was visualized in the aortic lumen, significant for an ascending aortic dissection.\u00a0 The dissection was then visualized in the abdominal aorta, extending distal to the common iliac arteries, seen in the last images.<\/span><\/p>\n

The patient was placed on esmolol drip and later required vasopressor support.\u00a0 CT angiography was obtained, confirming a Type A aortic dissection.\u00a0 He was transferred to a nearby hospital for emergent repair of his ascending and descending aortic dissection.\u00a0\u00a0<\/span><\/p>\n

Per the operative report, the patient had developed a significant pericardial effusion by the time he reached the OR, and the visualized homogenous layer above most likely represented a blood clot within the pericardium.<\/span><\/p>\n

Learning Points:<\/span><\/p>\n