Can you tell the difference between aortic dissection and aneurysm?
Aortic dissections and aortic aneurysms are often confused, so it's important for nurses to distinguish between the two, emphasizes Donna York, RN, MS, CFRN, chief flight nurse, nurse manager, Life Flight Medical Transport Program, Stanford University Hospital, UCSF-Stanford Health Care (CA). "People often refer to them as the same condition. Nurses often don't understand there is a difference, and one does not equal the other," she says.
Aortic aneurysm is a ballooning or an outpouching in the wall of the aorta, usually caused by atherosclerosis and hypertension, York explains. The bulging aneurysm may get in the way of the urinary tract or spine and cause pain.
A dissecting aneurysm involves a tear in the intimal layer of the aortic wall, usually causing severe pain. These are most commonly seen in males 40-60 years of age, and 90% of these patients have high blood pressure. "A dissection patient can have tearing, ripping pain, and cardiac tamponade, meaning they have bleeding in pericardium," York notes. "They may also have myocardial ischemia, because a dissection can start in the aorta and rip back, preventing blood flow to the cardiac muscle."
With a dissection, the goal is to stop the tearing. "The pressure is what's causing the tear, so the idea is to lower it," says York. "You definitely want to bring their blood pressure down and get them to a place that can be managed quickly. It's not the kind of thing you want to sit on forever, because the longer they are hypertensive, the more damage they are doing, and the worse the pain is going to be."
Abdominal aortic aneurysms often present with lumbar or abdominal mid-back pain. They can also have ischemic bowels, since, as their aneurysm expands, it results in an inadequate blood supply to the bowels, says York.
These patients may have a pulsatile mass upon physical exam, and often present with nausea or vomiting. "If there is a pulsatile mass in the belly, don't push on it," warns York. "You run the risk of rupture."
Before a diagnosis is made, treatment is often the same for both aneurysm and dissection. "Pre-diagnosis, we'll try to keep the mean arterial pressure in the 60-80 range, and we'll use beta blockers and nitroprusside to help us do those two things," York explains.
If it's an aneurysm, the physician makes a decision for surgery or medical management, such as medication to reduce blood pressure and relieve pain. "Sometimes the aneurysm itself isn't a big problem, and there are various standards as to whether a patient needs surgery or not," says York. "If patient's got a lot of symptoms, or can't move their bowels or breathe well, then surgery may be necessary."
Aortic aneurysms are often managed medically. "Depending on the size and patients symptoms they may or may not be life threatening," says York. "Investigation is integral to good patient care."
Aortic dissections may be a life and death emergency. Dissections are classified as Type A (before the aortic arch) and Type B (after the arch). "Type As are surgical emergencies requiring immediate intervention," says York. "In most cases, slow intervention results in death." Type Bs may require surgery or other intervention. This varies with patient presentation and physiology, she notes.