4th June 2026

Medical management

During your A-E examination, you need to think about controlling the BP, controlling any bleeding and very cautious fluid resuscitation.

• High-flow oxygen 
• 2x wide bore cannulas for IV access
• Invasive monitoring – arterial line, central venous catheter and a urinary catheter 
• Analgesia! – IV opiates 
• Cautious fluid replacement if required – discuss with senior team 
• Blood bank warned – Likely to require 6 units of cross-matched blood + additional products
• Control and active monitoring of HR and BP – Aiming for systolic BP of 100-120 and HR 60-80bpm
• Senior support from anaesthetics/critical care, vascular/ cardiothoracic surgeons and IR (interventional radiology) 
• If an aortic dissection has already been confirmed on imaging – urgent discussion is required with the on-call cardiothoracic/vascular team with urgent transfer organised.

How to manage the BP

It is essential to manage blood pressure in dissection patients due to the increased risk of further tearing with hypertension, and the risk of organ compromise with hypotension. This is why we aim for a BP of 100-120mmHg systolic and HR 60-80bpm.

• Monitor BP in both arms and target therapy at the higher reading. 
• An arterial line must be placed to ensure you are getting an accurate BP measurement. 
• Opiate analgesia will reduce the sympathetic stimulus of pain.
• First line = IV beta-block infusion (e.g, labetalol). However, labetalol has a half-life of 3-5 hours, which could cause complications if there is sudden bleeding or haemodynamic instability. Esmolol is being used more recently due to its short 9-minute half-life. 
• Second line = IV non-dihydropyridine calcium channel blockers (diltiazem or verapamil). These are rarely used, only where β-blockers are contraindicated. 
• If BP is still not controlled (refractory hypertension) and HR is around 60bpm, then IV nitrate-based vasodilators (i.e. GTN infusion) should be considered.