EMERGENCY CASE REPORT

Aortic Dissection Stanford B

DeBakey Type III

Resident :
dr. Rahageng Wida Kusuma
Supervisor :
dr. M. Arif Nugroho, Sp.JP(K), FIHA

DEPARMENT OF CARDIOLOGY AND VASCULAR MEDICINE

FACULTY OF MEDICINE DIPONEGORO UNIVERSITY
SEMARANG
2019
 ABSTRACT

A 57-year-old man felt chest pain since 8 hour prior to hospital admission.
The chest pain was like burning pain, accompanied with cold sweat, and nausea.
The chest pain didn’t radiate. Patient didn’t able to localize the pain. Patient felt the
chest pain persistantly, didn’t relieved with resting. The pain didn’t affected with
respiration or position. Patient denied any prior chest pain. Patient came to Sunan
Kalijaga Hospital 1 hour afterwards. Patient was diagnosed with heart attack and
required immediate procedure in Dr Kariadi Hospital. Patient got several
medication in Sunan Kalijaga Hospital first, then he got referred to Dr Kariadi
Hospital. Patient underwent primary percutaneous intervention.
In physical examination, the blood pressure was 120/70, heart rate
72x/minute, respiratory rate 20x/minute. In ECG, there was ST segment elevation
in lead II, III, aVF with reciprocal ST segment depression in lead I and aVL. There
was ST segment depression in lead V1, V2, and V3 as well, but the ST segment in
lead V7, V8, and V9 was normal. There was elevation in cardiac biomarker such as
CKMB and Troponin. Laboratory test showed leucocytosis, hypocalcemia and
elevation in LDL and total cholesterol.
According to anamnesis, physical examination, ECG, X-Ray and laboratory
test, this patient was diagnosed with acute inferior STEMI onset 8 hour Killip I
TIMI risk 1/14, with additional diagnosis with dyslipidaemia and hypocalcemia.

Keyword: STEMI

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 CASE ILUSTRATION

I. Patient Identity:
 Name : Mr. M
 Age : 65 years old
 Address : Katerban, Purworejo
 Occupation : Farmer
 Hospitalized : 19 February 2019
 Insurance : BPJS

II. Anamnesis (16 February 2019)

Alloanamnesis with patient’s family in ER.
Chief Complaint : Chest Pain
Recent Medical History:
Since about 2 weeks hour prior to hospital admission, patient suddently felt
chest pain. The chest pain was described as severely sharp “stabbing” pain which
radiated to the patients back and abdomen. Patient felt the chest pain persistenly
and didin’t relieved with resting.in in the chest. The pain didn’t affected with
respiration or position. There was no dypsnea, palpitation, syncope, fever, cold
sweat, nausea, and vomiting. Patient denied any prior chest pain. Patient went to
Panti Waluyo Hospital in Purworejo hospitalized for 1 week and the chestpain was
declining. Afterwards, patient was diagnosed with dilatation of abdominal aortic by
ultrasound examination and then transferred to Dr.Sardjito Hospital. Patient was
then diagnosed with Aortic Dissection and Abdominal Aortic Aneurysm after
Thoraco-abdominal MSCT Angiography. On the sixth day in dr.Sardjito Hospital,
the patient experienced another severe episode of the chest and abdominal stabbing
pain. Patient was then transferred to Dr. Kariadi Hospital. In Dr Kariadi Hospital’s
ER, the chest pain was severely increased.

 Coronary Artery Disease Risk Factor:

o Patient denied history of hypertension
o Patient denied history of Diabetes Mellitus

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o Patient denied history of dyslipidaemia
o There was no family history of heart disease
o Active smoker, 2 packs per day

 Prior Medication in Sunan Kalijaga Hospital

o Ringer Lactat Infusion 20 drops/minute
o Injection Heparin 500 unit/hour
o Injection Ranitidine 50mg
o Aspillet 160mg
o Clopidogrel 300mg
o ISDN 5mg sublingual, 2x

 Past Medical Illness

o Stroke (-)
o Allergy (-)
o Asthma (-)

 Social Economic State

The patient was a teacher in State Elementary School in Demak. Patient used
BPJS as insurance.

III. Physical Examination: (16 February 2019)

 General appearance : Composmentis, Severely in Pain (VAS 10)
 Weight : 60 kg
 Height : 161 cm
 Body mass index : 23.1 kg/m2 (overweight - WHO criteria)

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 Vital Sign

ER (19/02/19)

 Vital sign :
 BP : 202/110 196/100
188/105 192/104
 Heart Rate: 96X/ menit reguler, teraba kuat
 RR : 24x/mnt
 Suhu : 37 0c
 Saturasi: 98 % (O2 nasal canule 3 lpm)

 Eyes:
- Pale conjunctiva palpebra + | +
- Icteric in sklera - | -
 Mouth : Cyanosis (-), Oral thrush (-)
 Neck :
o JVP = R + 3 cmH2O
o Hepatojugular reflux (-)
 Thorax:
o Cor:
 Inspection : Ictus cordis was not seen
 Palpation:
Ictus kordis was palpated in 5th Intercostal Spatium Left Midclavicularis
Line, thrill (-), parasternal pulsation (-), sternal lift (-), epigastrial pulsation
(+)
 Auscultation:
- S1 – S2 regular
- Murmur (-)
- Gallop (-)

 Lungs:

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 Inspection : Symetric in static and dynamic state
 Palpasi : Stem fremitus were equal in both side
 Percussion : Sonor in all fields
 Auscultation:
- Vesicular in all fields
 Coarse Crackles (-)
 Fine Crackles (-)

 Abdomen:
o Inspection : distended (-)
o Auscultation : Peristaltic sound was normal
o Percussion:
- Shifting dullness (-)
o Palpation
- Tender mass (+) size > 5 cm , pulsatile (+), tenderness (+), immobile
(+)
- Hepar and spleen were not palpated
 Extremities
o Cyanosis : (-)
o Oedema : (-)
o Warm extremities (+)

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IV. Additional Examination
ECG
1. ECG I (Kariadi Hospital 19/2/2019 )

ECG Interpretation
 Rhythm : Sinus
 Rate : 82 x/ minute
 Axis : Normal
 P wave : normal, P mitral (-), P pulmonal (-)
 PR interval : 0,16 second
 QRS complex : Duration 0,04 second
 Morfology QRS : Rsr in V1,V2
 ST segment : ST depression upslopping in V1-V4
 T wave : inverted T wave (+) lead III
 Conclusion : Sinus rythim , HR 82x/minute, normo axis, complete
RBBB
  Imaging X Ray (19 /2/2019)

Thorax X-Ray Description (PA):

o Cardio Thoracic Ratio 60%
o Aortic elongatio (+)
o Aortic dilation (+)
o Pulmonal segment not indented
o Cardiac waist (+)
o Double contour appearance (+)
o Right cardiac border > 1/3 right hemithorax
o Bronchovascular pattern slightly marked
o Sharp left and right costophrenic angle
Conclussion
There was cor enalrgement, aortic elongation and dilatation

MSCT

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BACAAN

 Tampak massa memanjang dari intrathoracal sinistra

intraabdominal superior
 Ada kalsifikasi pada dinding dari massa
 Terdiri dari 2 komponen utama yakni yang memberikan
enhasemen nyata pada pemberian kontras dan yang lainnya
memberikan enhasmen ringan
 Yang memberikan enhasemen nyata ternyata adalah aorta
thoracalis yang melebar
 Bronchus sinistra dan a. pulmonalis sinistra terdesak keatas
 Trachea dan bifurcatio trachea deviasi kekanan
 Tak tampak kelainan pleura
 Tak tampak pembesaran ln regional
 Cor suspect membesar ringan

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 Kesan:
 Aneurysma aorta thoracales
 Bagian yang oval dengan enhasemen tinggi adalah lumen aorta
yang asli
 Bagian yang semiluner dengan enhasemen kurang mungkin
bukan lumen asli dengan kandungan deposit thombotik juga.

 Laboratory Result :

NORMAL
PARAMETER 19/2 22/2 28/2 UNIT
VALUE

Haemoglobin 10.1 9.8 gr% 12-15

Hematocrite 27.9 29.4 % 35-47
Eritrocyte 3.33 3.36 106/uL 3,9-5,6
MCH 30.3 29.2 Pg 27-32
MCV 83.8 87.5 fL 76-96
MCHC 36.2 33.3 g/dL 29-36
Leukocyte 10.5 4.1 103/uL 4-11
Trombocyte 453 230 103/uL 150-400
RDW 13.5 13.8 % 11,6-14,8
MPV 9.3 10.8 Fl 4-11
Blood Glucose 98 mg/dl 80-160
Ureum 34 mg/dl 15-39
Creatinin 0.72 mg/dl 0,6-1,3
Natrium 129 138 mmol/L 136-145
Kalium 3.7 4.1 mmol/L 3,5-5,1
Chlorida 97 105 mmol/L 98-107
Calcium 2.1 mmol/L 2,12-2,52
Magnesium 0.91 mmol/L 0,74-0,99

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 PARAMETER UNIT NORMAL VALUE
D dimer Quantitative 3630 ug/L 0-500
Fibrinogen 495 mg/dL 200-400
HbsAg <0.1 Negative<1
Protrombin time 14.4 second 11.0-14.5
Control PPT 14.9 second
PTTK 32.7 second 24.0-36
Control APTT 33.1 second

BGA

21/2/2019 Unit Normal Value

FiO2 21.0 %

pH 7.449 7.37- 7.45

pO2 194.0 MmHg 83.0-108.0

pCO2 24.5 MmHg 35-45

HCO3 17.1 Mmol/L 22-26

BE -5.3 Mmol/L -2 - 3

V. Working Diagnosis
1. Acute Aortic Dissection Stanford A De Bakey Type I
2. Emergency Hypertension
3. Anemia normositic normochromic
4. Hyponatremia
5. Hypochlorida

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VI. Management in ER

• IVFD NaCl 0.9% 10dpm

• Inj. Nicardipine 2 mg/hour (IVSP titrated adjustable dose)
• Inj Morphine 0.5 cc/ hour ( IVSP)
• PO Micardis 80 mg/24 hours
• PO Concor 5 mg/24 hours
• PO Diazepam 5 mg/ 24 hours

Program

• Close Vital Sign Monitoring (Target SBP <110 mmHg, HR <60

x/minute)
• Send to ICU
• MSCT Angiography

VII. FOLLOW UP IN ER
Date Follow Up Management

20/2/2019 Complaint : Chest pain (-), Management in ER

abdominal pain (+)
 IVFD NaCl 0.9% 10dpm
General appearance :
 Inj. Nicardipine 2
Compos mentis, Severely in
mg/hour (IVSP titrated
Pain (VAS 8)
adjustable dose)
 Weight
 Inj Morphine 0.5 cc/ hour
: 60 kg
( IVSP)
 Height
 PO Micardis 80 mg/24
: 161 cm
hours

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  Body mass index  PO Concor 5 mg/24
: 23.1 kg/m2 hours
(overweight - WHO criteria)  PO Diazepam 5 mg/ 24
hours
 Vital sign :
 BP : 144/67 136/72
Program
140/78 146/78
 Heart Rate: 57X/  Close Vital Sign
minute reguler, Monitoring (Target SBP
 RR : 15x/mnt <110 mmHg, HR <60

 Suhu : 36.5 0c x/minute)

 Saturasi: 100 % (O2  Send to ICU

nasal canule 3 lpm)  MSCT Angiography

 Eyes:
- Pale
conjunctiva
palpebra + | +
- Icteric in sklera
-|-
 Mouth : Cyanosis (-
), Oral thrush (-)
 Neck :
o JVP = R + 3 cmH2O
o Hepatojugular
reflux (-)
 Thorax:
o Cor:
 Inspection : Ictus
cordis was not seen
 Palpation:

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 Ictus kordis was
palpated in 5th
Intercostal Spatium
Left Midclavicularis
Line, thrill (-),
parasternal pulsation
(-), sternal lift (-),
epigastrial pulsation
(+)
 Auscultation:
- S1 – S2 regular
- Murmur (-)
- Gallop (-)
 Lungs:
 Inspection :
Symetric in static and
dynamic state
 Palpasi :
Stem fremitus were equal in
both side
 Percussion :
Sonor in all fields
 Auscultation:
- Vesicular in all
fields
 Coarse Crackles (-)
 Fine Crackles (-)

 Abdomen:
o Inspection :
distended (-)

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o Auscultation :
Peristaltic sound was
normal
o Percussion:
- Shifting
dullness (-)
o Palpation
- Tender mass
(+) size > 5 cm
, pulsatile (+),
tenderness (+),
immobile (+)
- Hepar and
spleen were not
palpated
 Extremities
o Cyanosis : (-)
o Oedema : (-)
Warm extremities
(+)

Working Diagnosis
1. Acute Aortic Dissection
Stanford A De Bakey
Type I
2. Emergency
Hypertension
3. Anemia normositic
normochromic
4. Hyponatremia
5. Hypochlorida

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21/2/2019 Complain : chest pain (-),
abdominal pain (+)
 IVFD NaCl 0.9% 10dpm
General appearance :
 Inj. Nicardipine 2
Composmentis, Severely in
mg/hour (IVSP titrated
Pain (VAS 7)
adjustable dose)
 Weight
 Inj Morphine 0.5 cc/ hour
: 60 kg
( IVSP)
 Height
 PO Micardis 80 mg/24
: 161 cm
hours
 Body mass index
 PO Concor 5 mg/24
: 23.1 kg/m2
hours
(overweight - WHO criteria)
 PO Diazepam 5 mg/ 24
hours

 Vital sign :
 BP : 113/68 Program
 Heart Rate: 60X/
 Close Vital Sign
menit reguler,
Monitoring (Target SBP
teraba kuat
<110 mmHg, HR <60
 RR : 14x/mnt
x/minute)
 Suhu : 36.5 0c
 Send to ICU
 Saturasi: 100 % (O2
nasal canule 3 lpm)
 Eyes:
- Pale
conjunctiva
palpebra + | +
- Icteric in sklera
-|-

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 Mouth : Cyanosis (-
), Oral thrush (-)
 Neck :
o JVP = R + 3 cmH2O
o Hepatojugular
reflux (-)
 Thorax:
o Cor:
 Inspection : Ictus
cordis was not seen
 Palpation:
Ictus kordis was
palpated in 5th
Intercostal Spatium
Left Midclavicularis
Line, thrill (-),
parasternal pulsation
(-), sternal lift (-),
epigastrial pulsation
(+)
 Auscultation:
- S1 – S2 regular
- Murmur (-)
- Gallop (-)

 Lungs:
 Inspection :
Symetric in static and
dynamic state

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 Palpasi :
Stem fremitus were equal in
both side
 Percussion :
Sonor in all fields
 Auscultation:
- Vesicular in all
fields
 Coarse Crackles (-)
 Fine Crackles (-)

 Abdomen:
o Inspection :
distended (-)
o Auscultation :
Peristaltic sound was
normal
o Percussion:
- Shifting
dullness (-)
o Palpation
- Tender mass
(+) size > 5 cm
, pulsatile (+),
tenderness (+),
immobile (+)
- Hepar and
spleen were not
palpated
 Extremities

o Cyanosis : (-)

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o Oedema : (-)
Warm extremities (+)
Working Diagnosis
1. Acute Aortic Dissection
Stanford A De Bakey
Type I
2. Emergency
Hypertension
3. Anemia normositic
normochromic
4. Hyponatremia
5. Hypochlorida

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LITERATURE REVIEW

DISCUSSION

BIBLIOGRAPHY

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