Acute aortic syndromes and aortic dissection

Manage now— do this, in order

• Start treatment as soon as the diagnosis is considered — lower blood pressure and heart rate aggressively even before definitive imaging; if the scan later shows something else, an opioid and a beta-blocker is a survivable error, unlike the alternative.
• Actively withhold antiplatelet drugs, anticoagulants and thrombolytics while the aortic question is unsettled — they convert a contained dissection into an uncontained haemorrhage; if already given, tell the surgical team.
• Set the targets: systolic below 120 mmHg and heart rate below 60/min within 30 minutes, target MAP 60–75 mmHg — the correct pressure is the *lowest* that preserves consciousness, urine output and perfusion; confusion, oliguria or rising lactate means overshoot.
• Analgesia treats the aorta: morphine 2.5–5 mg slow IV, repeated every 5–10 minutes (child 100 micrograms/kg, max initial 5 mg) — pain drives the catecholamine surge that drives the dissection. Add metoclopramide 10 mg IV, but ondansetron 100 micrograms/kg (max 4 mg) in anyone under 20 years.Doctor / Nurse
• Rate before pressure — labetalol first line: 20 mg slow IV over 2 minutes, repeat 20–80 mg every 10 minutes until rate < 60/min and systolic < 120 mmHg, cumulative maximum 300 mg, then infusion 0.5–2 mg/minute (paediatric 0.2–1 mg/kg per dose, max 20 mg). Esmolol 500 micrograms/kg over 1 minute then 50–200 micrograms/kg/minute where the response is uncertain. Labetalol is the beta-blocker of choice in pregnancy.Doctor / NurseNot available at your setup — Infusion pump. If beta-blockers are contraindicated: diltiazem 0.25 mg/kg slow IV over 2 minutes, then 5–15 mg/hour — never after a beta-blocker has been given.
• Add a vasodilator only once the rate is controlled and systolic remains above 120 mmHg: sodium nitroprusside 0.3 micrograms/kg/minute titrated (usual 0.5–3, max 8), light-protected line with continuous pressure monitoring; or glyceryl trinitrate 2–10 mg/hour. Never a vasodilator before beta-blockade — alone it raises dP/dt and extends the tear.Doctor / NurseNot available at your setup — Infusion pump.
• The hypotensive patient — everything inverts: hypotension means tamponade, rupture or severe aortic regurgitation; withhold beta-blockers and vasodilators, give cautious 250 mL crystalloid boluses (10 mL/kg in children) reassessing after each, transfuse if there is haemorrhage. Request group, save and crossmatch at the point of suspicion, not of haemorrhage. Pericardiocentesis is not a reflex — it can precipitate fatal haemorrhage; needle drainage is a bridge for the peri-arrest patient only.Doctor / Nurse
• Image definitively — CT angiography is the acute test: coverage from thoracic inlet to femoral heads, with an unenhanced acquisition before contrast (intramural haematoma may be invisible once contrast is given). Type A needs emergency surgery to replace the ascending aorta; type B is treated medically unless there is rupture, vital-organ or limb ischaemia — medical therapy means sustained anti-impulse therapy with serial pulses, neurology and urine output.Not available at your setup — CT scan. No CT locally: start analgesia and beta-blockade and transfer in parallel — referral must not wait for imaging.