Aortic dissection physical examination

Aortic dissection Microchapters
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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Vitals

Blood Pressure

While many patients with an aortic dissection have a history of hypertension, the blood pressure is quite variable at presentation with acute aortic dissection, and tends to be higher in individuals with a distal dissection. In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. In those that present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension.

Severe hypotension at presentation is a grave prognostic indicator. It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta. Accurate measurement of the blood pressure is important. Pseudohypotension (falsely low blood pressure measurement) may occur due to involvement of the brachiocephalic artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

Pulse

• Tachycardia may be present due to pain, anxiety, aortic rupture with massive bleeding, pericardial tamponade, aortic insufficiency with acute pulmonary edema and hypoxemia.
• A wide pulse pressure may be present if acute aortic insufficiency develops.

General

The patient may be hoarse due to compression of the left recurrent laryngeal nerve

Head, Eyes, Ears, Nose, Throat

• Cardiac tamponade, hemothorax, Horner syndrome,
• Descending dissection can lead to splanchnic ischemia, renal insufficiency

Heart

• Aortic regurgitation is present in approximately 40 – 66 % of patients and is almost always seen in those with type I or type II dissection. The murmur of aortic insufficiency (AI) due to aortic dissection is best heard at the R 2nd intercostal space (ICS), as compared with the lower left sternal border for AI due to primary aortic valvular disease.

Lungs

Rales may be present due to cardiogenic pulmonary edema

Extremities

Diminution or absence of pulses is found in up to 40% of patients, and occurs due to occlusion of a major aortic branch. For this reason it is critical to assess the pulse and blood pressure in both arms.

Neurologic

• Neurologic deficits such as coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%.
• There can also be focal neurologic signs due to occlusion of a spinal artery. This condition is known as Anterior spinal artery syndrome or "Beck's syndrome".