EEM Rewind: Crashing Aortic Dissection

Rob Orman, MD and George Willis, MD

on Spotify

The summary below is from an episode of ERcast: Clinical Perspectives

Acute type A aortic dissection that suddenly decompensates is usually declaring a complication, not a medication problem. Bedside ultrasound rapidly separates tamponade from aortic root dilation with severe aortic insufficiency, and that distinction changes what you do before the OR.

Crashing Aortic Dissection Approach

It’s not the drip: Sudden hypotension in a dissecting patient is far more likely to reflect tamponade or cardiogenic shock than over-titrated antihypertensives, so reflexively backing off the infusion is rarely the fix.
Ultrasound-first deterioration check: Use bedside ultrasound early and liberally when the pressure falls; the high-yield search is for pericardial fluid, RV collapse, or a dilated aortic root. We walk through that scan sequence in the episode.
Tamponade before intubation: Hemodynamically unstable dissection plus tamponade is a peri-intubation arrest setup, so evaluate for fluid in the sac and RV collapse before reaching for RSI.
Resuscitate before intubate: RBI is the governing principle here: stabilize hemodynamics first, using a shock index goal of 0.7 or less rather than pushing ahead with an unstable airway plan.
Controlled pericardial drainage: Early pericardiocentesis can be lifesaving in tamponade, but the key is controlled drainage with small aliquots only—enough to restore perfusion without suddenly increasing the leak pressure.
Aortic insufficiency physiology: Aortic root dilation causing acute aortic regurgitation often declares itself with refractory tachycardia; management priority is blood pressure support and control, not aggressive heart-rate chasing.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Hayashi T, et al. Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection. Circulation. 2012;126(11 Suppl 1):S97-S101. PMID: 22966000.
Isselbacher EM, et al. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful?. Circulation. 1994;90(5):2375-2378. PMID: 7955196.
Cruz I, et al. Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery. Eur Heart J Acute Cardiovasc Care. 2015;4(2):124-128. PMID: 25182464

Faculty

Rob Orman, MD
Dr. Rob Orman is an emergency physician, educator, and executive coach specializing in physician performance and professional fulfillment. After more than 20 years in community emergency medicine, he now works with clinicians across specialties to address burnout, inefficiency, and career challenges. He earned his medical degree from Emory University School of Medicine and completed his residency at Denver Health Medical Center, where he served as chief resident. Dr. Orman is the founder of the Stimulus podcast and Orman Physician Coaching. He previously served as chief editor of ERcast and hosted Essentials of Emergency Medicine for nearly a decade.
George Willis, MD