ED MANAGEMENT

The patient should be placed in a high acuity area, on a cardiac monitor, with
intravascular access established with at least
two large-bore catheters (16 gauge or larger). The goals of ED management
are to reduce the arterial blood pressure and to
decrease the forceful contractility of the left ventricle, in an attempt to limit
the propagation of the dissection. Systolic
blood pressure control is important because the rate of dissection is directly
proportional to the rate of rise of arterial
blood pressure. The systolic blood pressure should be maintained at 100 to
110 mm Hg (mean arterial pressure of 60 to 80
mm Hg) or the lowest level compatible with adequate renal and cerebral
perfusion. This is best achieved by titrating
intravenous (IV) medications. Direct arterial blood pressure monitoring (e.g.,
through a radial arterial catheter) can aid
management but should not delay treatment. If suspicion for dissection is
high, treatment should be initiated rapidly and
before confirmatory tests are performed.
-blockers are rst line for controlling blood pressure in aortic dissection but
are relatively contraindicated with known
or suspected cocaine toxicity. Esmolol IV is the drug of choice (0.5 mg/kg
loading dose in 1 minute, infusion rate of 0.05
mg/kg/min). Propranolol IV may also be used (0.5 to 1 mg increments at 5minute intervals) as well as metoprolol or
labetalol. Acute congestive heart failure, heart block, and bradycardia are
contraindications to -blocker use. Nitroprusside
IV at an initial rate of 0.5 to 1 g/kg/min or nicardipine IV (5 mg/hr
initially) can be added or additional blood pressure

control after -blockers have been initiated. Fenoldopam IV (0.1 g/kg/min

initially) is a dopamine-1 agonist that can be
used as an alternative to nitroprusside in patients with renal impairment, but
it has a longer half-life (5 to 9 minutes) and
may cause reex tachycardia and ECG changes. Verapamil IV or diltiazem IV
may also be used if -blockers are
contraindicated. Morphine IV can also assist in reduction of blood pressure by
treating pain associated with the dissection.
Oral agents should never be used in the emergency setting for patients with
suspected or confirmed aortic dissection.