Patients with suspected aortic dissection will commonly require antihypertensive treatment, which must be provided without increasing the shear force on the intimal flap of the aorta. Therefore, medications with negative inotropic effects must be given initially. b blockers (esmolol, metoprolol, or propranolol) are commonly used for this purpose. The optimal blood pressure is undefined and must be tailored to each patient. However, systolic pressure of 120 to 130 mmHg may be a convenient starting point.
Esmolol may be given as an infusion of 500 pg/kg over 1 min followed by an infusion of 50 to 150 pg/kg per minute. Metoprolol may be given intravenously in three 5-mg doses every 2 min followed by 2 to 5 mg/h. Labetolol, 20 mg (or 0.25 mg/kg) IV over 2 min, repeated q10 min to desired effect or a total dose of 300 mg; or labetolol 2 mg/min to desired effect or total dose 300 mg, can also be given. Calcium channel blockers may be used if a contraindication to b blockers is present.
Vasodilators (such as nitroprusside) may be added for further antihypertensive treatment after the successful administration of a negative inotrope. Nitroprusside may be infused intravenously at 0.3 to 10 pg/kg per minute. Administration should be provided by a pump to ensure precise measurement of drug. Patients should clearly have evidence of adequate b-receptor or calcium channel blockade prior to starting a vasodilator. Close monitoring of the pulse rate is required, as this is a convenient indicator of blockade in most patients. Aortic dissections may cause hypotension, which requires fluid or blood product resuscitation.
Rapid referral to a surgeon is mandatory. Dissections with involvement of the ascending aorta require prompt surgical repair. Patients with dissecting aneurysms of only the descending aorta are worse surgical risks, and indications for repair are controversial. 18
Asymptomatic abdominal and thoracic aortic aneurysms require prompt outpatient referral. Other interventions are generally not needed. CHAPTER REFERENCES
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