Transcript It’s not just blood pressure…it’s poor impulse control!

It’s not just blood pressure…it’s poor
impulse control!
• dP/dt
– Change in pressure per
Unit of time
Anti-impulse therapy
• Negative inotropy (and thus rate of rise of blood
pressure, as well as mean and peak systolic pressure)
• Negative chronotropy (fewer peak systolic pressures
for the vulnerable vessel to experience)
• Alpha blockade (prevent compensatory
vasoconstriction)
Goal blood pressure: as low as possible without
inducing organ failure….Systolic BP of 100, or MAP of
60-70.
No great evidence; this would be a tough population to
ethically randomize.
Pharmacologic options: with invasive
monitoring
• Esmolol: Beta blocker, bolus and infusion options
– 1 mg/kg (usually about 80 mg) bolus
– 150-300 mcg/kg/min
• Labetalol: alpha-antagonistic properties
– 20 mg IV bolus (may require up to 80 mg over 10 min)
– 0.5-6 mg/min infusion
• Propranolol: 1-10 mg bolus, followed by 3 mg/hr
Others
• Nitroprusside: beware cyanide toxicity (at about 500
mcg/kg). Do not use without beta-blockade (reflex
tachycardia)
– 0.5 mcg/kg/min, titrate in 0.5 increments to max 10
mcg/kg/min
• ACE inhibitors may be used, but given the high risk of renal
failure, and unreliable gut function depending upon the
course of the dissection, they would not be plan A.
• For patients who cannot tolerate beta blockers, non-DHP
calcium channel blockers (verapamil or diltiazem) are viable
options.
• 4. Quit eating fast food and check into rehab.
Again.
Classification systems for Thoracic
Aortic Dissections
• Time course: Acute vs. Chronic
• Anatomical: Ascending, descending or both
• Stanford:
– Type A: Involving the ascending aorta (with or without
descending aortic involvement)
– Type B: Involving only the descending aorta
• De Bakey:
– I: Ascending and Descending aorta
– II: Ascending Aorta only
– III: Descending Aorta only