The primary determinants of morbidity and mortality are extent, size, and location. Rupture of the intimal and medial aortic layers is less ominous in the short term as a pseudoaneurysm forms. Although hemorrhage is minimal, proximal increases in afterload and distal ischemia are risks. A larger aortic tear results in rapid and significant blood loss. A retroperitoneal rupture may be temporarily more stable than the almost always fatal intraabdominal rupture.
Resuscitation should be done in the operating room since rapid surgical intervention is necessary to prevent death. Rapid airway control must be obtained to optimize ventilation and oxygenation. The initial goal is to maintain perfusion and oxygenation to the heart and brain. Efforts are directed toward intravascular volume restoration. Multiple large bore intravenous lines are necessary, as is intra-arterial monitoring and probably central venous pressure monitoring as well. Transesophageal echocardiography or pulmonary artery catheterization may be valuable when preexisting myocardial dysfunction is present, but vigorous intravascular restoration and treatment of the inevitable coagulopathy should take precedence. The patient should have 10 units of blood available, universal donor blood if necessary, and the laboratory should be made aware that this case will probably require massive transfusion, with requirements for fresh frozen plasma, platelets, and cryoprecipitate. Disturbances in coagulation are best followed with thromboelastography. Blood pressure may require inotropic or chronotropic support, although volume resuscitation is the mainstay of treatment. A systolic blood pressure of 80 to 100 mm Hg is an ideal goal, although communication about hemodynamic goals should involve the surgeons.
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