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Critical Care / ICU · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Tearing interscapular pain, BP 210/120, right arm pulse weaker than left — kill the shear forces: β-block FIRST, then vasodilate, then CTA.
Red flags Tearing/migratory pain Pulse deficit or interarm BP >20 mmHg New diastolic murmur (AR) Syncope, tamponade, stroke with chest pain Differential diagnosis ACS (ECG + troponin — but dissection can cause it) Pulmonary embolism Musculoskeletal pain Pericarditis When to admit, call ICU or discharge Type A: Emergency surgery — any ascending involvementType B: Medical impulse control; TEVAR if complicatedHR target: 60–80 bpm BEFORE SBP <120Key points HR first, BP second — both controlled within the first 20 minutes of suspicion Type A mortality rises ~1% per hour — the CT table is the bottleneck, not the diagnosis Interarm SBP difference >20 mmHg or new AR murmur = dissection until CTA proves otherwise Never Vasodilate before β-blockade — reflex tachycardia extends the dissection Thrombolyse the 'STEMI' — dissection mimics it and lysis is fatal Wait for troponin/d-dimer to rule it in or out Common mistakes Nitroprusside started first Analgesia forgotten — pain defeats every infusion Single normal troponin = false reassurance D-dimer used as rule-out (not validated) Disposition and follow-up Type A → theatre; type B → ICU 48–72 h then ward with oral β-blocker; lifelong BP control + surveillance imaging at 1, 6, 12 months.
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