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92 Aortic dissection
Citing sedative and anxiolytic properties, expert reviewers recommend
morphine for AD pain, but there is no evidence demonstrating its superiority
over other opioids. 1,4 Patients in pain from AD tend to be hypertensive, but in
those cases where blood pressure is borderline or low, fentanyl’s limited
hemodynamic impact is attractive. 6,7 Anesthesiologists confirm fentanyl’s
utility for AD, including in cases where there are complicating conditions
such as subarachnoid hemorrhage or pregnancy. 8–11
n Summary and recommendations
First line: morphine (initial dose 4–6 mg IV, then titrate);
standard anti-impulse therapy (e.g. beta-blockers, vasodilators)
Reasonable: other opioid agonists such as hydromorphone (initial dose 1 mg
IV, then titrate)
Pregnancy:fentanyl(initialdose50–100 μgIV, then titrate); avoid nitroprusside
if possible
Pediatric: morphine (initial dose 0.05–0.1 mg/kg IV, then titrate)
Special case:
n hypotension or concern for hemodynamic instability: fentanyl (initial dose
50–100 μg IV, then titrate)
References
1. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic
dissection. Eur Heart J. 2001;22:1642–1681.
2. Winsor G, Thomas S, Biddinger P, et al. Inadequate hemodynamic management
in patients undergoing interfacility transfer for suspected aortic dissection.
Am J Emerg Med. 2005;23:24–29.
3. Khoynezhad A, Plestis KA. Managing emergency hypertension in aortic dissection
and aortic aneurysm surgery. J Card Surg. 2006;21(Suppl 1):S3–S7.
4. Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and
management. Part II: therapeutic management and follow-up. Circulation.
2003;108:772–778.