Tearing interscapular pain, BP 210/120, right arm pulse weaker than left — kill the shear forces: β-block FIRST, then vasodilate, then CTA.
ABCDE
High-flow O₂; 2 large-bore IVs; esmolol or labetalol BEFORE any vasodilator; target HR <60 then SBP 100–120; urgent CTA chest/abdomen; type A = emergency surgery.
Suspect: tearing chest/back pain ± pulse deficit, aortic regurgitation murmur, widened mediastinum; mortality ~1% per hour untreated — CTA chest/abdomen/pelvis now
Stabilise access + tests: 2 large-bore IVs, crossmatch 6 units, ECG (dissection can occlude the right coronary — STEMI mimic), lactate, U&E
Impulse control FIRST: esmolol 500 mcg/kg load then 50–200 mcg/kg/min, or labetalol 20 mg IV q10 min — target HR <60 bpm before any vasodilator
Then BP 100–120 mmHg: add nicardipine 5→15 mg/h or nitroprusside ONLY after β-blockade — unopposed vasodilation raises shear stress and extends the flap
Type A (any ascending): emergency cardiothoracic surgery regardless of stability — call the surgeon while scanning; type B → medical therapy unless malperfusion/rupture → TEVAR
Analgesia + monitor: fentanyl for pain (drives BP); arterial line; strict hourly urine output — malperfusion watch (kidneys, gut, limbs)
Order set
- Esmolol or labetalol IV (HR <60)
- Nicardipine infusion after β-blockade
- CTA chest/abdomen/pelvis
- Crossmatch 6 units
- Arterial line
- Fentanyl analgesia
- Urine catheter — hourly output
- Cardiothoracic + vascular surgery consult
Monitor
- ContinuousInvasive BP both arms, HR — HR <60 before SBP target
- q15 minNeurology, limb pulses, urine output (malperfusion)
- q1 hLactate if malperfusion suspected
- SerialCreatinine, Hb — expanding haematoma
Escalate / ICU
- Type A — always surgical emergency
- Malperfusion: anuria, lactate rising, limb ischaemia, stroke
- Rupture signs: tamponade, haemothorax, shock
- BP uncontrolled on dual infusion
Criteria
Type AEmergency surgery — any ascending involvement
Type BMedical impulse control; TEVAR if complicated
HR target<60 bpm BEFORE SBP 100–120
DefinitiveSurvival tracked hourly until theatre/repair
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
Key
- 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
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Tearing/migratory pain
- Pulse deficit or interarm BP >20 mmHg
- New diastolic murmur (AR)
- Syncope, tamponade, stroke with chest pain
Differentials
- ACS (ECG + troponin — but dissection can cause it)
- Pulmonary embolism
- Musculoskeletal pain
- Pericarditis
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 & 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.
💊 Treatment detail — doses & preparation
EsmololIV β-blocker
DoseLoad 500 mcg/kg over 1 min, then 50–200 mcg/kg/min
Preparation2.5 g in 250 mL (10 mg/mL) ready bag via pump; titrate q5–10 min
MonitorHR <60 target in dissection; watch for bronchospasm, bradycardia
Labetalol IVIV α+β-blocker
Dose20 mg IV over 2 min, repeat 20–80 mg q10 min (max 300 mg) or 0.5–2 mg/min infusion
Preparation200 mg in 160 mL (1.25 mg/mL) for infusion; boluses undiluted (5 mg/mL vial)
MonitorAvoid in asthma/decompensated HF; postural hypotension
NicardipineIV dihydropyridine
Dose5 mg/h IV, ↑2.5 mg/h q5–15 min to max 15 mg/h
Preparation25 mg in 250 mL D5W/NS (0.1 mg/mL) via pump; central line preferred (vesicant)
MonitorMAP, reflex tachycardia; change site if peripheral >12 h
Fentanylopioid analgesic
Dose25–100 mcg IV boluses; infusion 0.5–2 mcg/kg/h
Preparation100 mcg/2 mL ampoule undiluted for bolus; infusion 1 mg in 50 mL NS
MonitorRR, sedation score; less hypotension than morphine
📖 ACC/AHA aortic disease guideline + textbook Ch.21Reviewed July 2026