Attending Version: Back Pain Emergencies Module; created by Dr. Wendy Gerstein

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Correct answer is B.
This is a type B aortic dissection (type A involves the ascending aorta, all others are type B). Proper management entails ICU monitoring, arterial line, pain control with morphine, target SBP 100-120 initially using short acting IV beta blockers, and then adding nitroprusside if creatinine is normal. Of note, nitroprusside should not be used without beta blockade since vasodilation alone induces reflex activation of the sympathetic nervous system which will lead to enhanced ventricular contraction and increased aortic shear stress. Most type B dissections improve with medical management only, and there is no emergent need for surgical intervention, although the surgeons should be consulted immediately as there is 10% mortality in hospitalized patients. Aortography has fallen out of favor with CT scans and TTE/TEE having low invasiveness and high sensitivity/specificity. In addition, MRI can be useful if patient is stable and able to tolerate the exam. If patient is unstable, they should be intubated and stabilized hemodynamically. Type B dissections are treated with surgical management if the dissection is complicated (associated ischemia/large vessel occluded) or continues/extends even with medical management. There is a role for stent grafting in Type B dissections, but the best outcomes were after patient had been medically managed for 8 weeks prior to procedure. There is some data that suggests acute management of complicated type B dissections with stent graft may have lower mortality than traditional surgical management, but this is still being investigated.

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