A 62-year-old man is brought to the emergency department with sudden-onset, severe, tearing chest pain that radiates to his back. He has a history of poorly controlled hypertension. Upon arrival, he appears lethargic and diaphoretic. Blood pressure is in the right arm and in the left arm. Pulse is , and respirations are . Physical examination shows significant jugular venous distention. The lungs are clear to auscultation bilaterally. Heart sounds are distant and muffled. A bedside echocardiogram demonstrates a dilated aortic root with an intimal flap, as well as a large pericardial effusion with right ventricular diastolic collapse. Which of the following is the most appropriate next step in management?
- Emergent surgical repair of the ascending aortaCevap
- BComputed tomography angiography of the chest
- CPercutaneous pericardiocentesis
- DIntravenous administration of labetalol
- EIntravenous administration of furosemide
Cevap
Emergent surgical repair of the ascending aorta
The correct answer is emergent surgical repair of the ascending aorta. This patient's presentation of tearing chest pain, hypotension, jugular venous distention, and muffled heart sounds is highly suspicious for an aortic dissection complicated by cardiac tamponade. The bedside echocardiogram confirms a Stanford Type A dissection (involving the ascending aorta) with an intimal flap, as well as right ventricular diastolic collapse, which is the hallmark echocardiographic sign of tamponade. A Type A dissection is a surgical emergency. When complicated by rupture into the pericardial space causing cardiogenic/obstructive shock, the patient must be taken immediately to the operating room to replace the diseased aortic segment and evacuate the pericardial blood.
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Acute Type A aortic dissection complicated by cardiac tamponade requires emergent surgical repair; pericardiocentesis is generally contraindicated as it can precipitate fatal aortic rupture.
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