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cardio.cardiac-tamponade.aortic-dissection-related.v1

Cardiac tamponade — Type A aortic dissection-related (hemopericardium)

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to Type A aortic dissection-related hemopericardium with tamponade. Inherits drainage + bridge regimen from parent via routing BUT critically OVERRIDES the reflexive full pericardiocentesis with LIMITED ≤50 mL bridge drainage ONLY if hypotensive per Hayashi Circ J 2012 + IRAD subgroup analyses + ACC/AHA 2022 PMID 36066317. Specializes for dissection-specific patterns: anti-impulse therapy with esmolol IV (HR <60) BEFORE adding nicardipine (SBP <120) — isolated vasodilator AVOIDED due to reflex tachycardia propagating dissection (ACC/AHA 2022 Class I); EMERGENT cardiothoracic surgery activated SIMULTANEOUSLY with imaging confirmation; CTA chest definitive (or TEE in unstable patient); thrombolytics ABSOLUTE CONTRAINDICATION; severity triggers cover malperfusion syndrome, dissection extension on serial CT, paraplegia from spinal artery compromise, organ-system progression, and pre-operative arrest scenarios. Long-term BB + ARB anti-impulse therapy (target SBP <130 + HR <70), genetic counseling for heritable connective tissue disorders, lifelong CT surveillance. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (dissection-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (5)

  • symptom
    Sudden tearing chest/interscapular back pain + Beck triad (hypotension + JVD + muffled heart sounds) — Type A dissection with tamponade until proven otherwise (ACC/AHA 2022 PMID 36066317)
    tearing_chest_back_pain_with_beck_triad
  • imaging
    STAT TTE: aortic root dissection flap + pericardial effusion + RV diastolic collapse → Type A dissection-related tamponade (Class I; ACC/AHA 2022; ESC 2014)
    echo_root_dissection_flap_plus_pericardial_effusion
  • imaging
    CTA chest (definitive when stable enough): ascending aorta dissection flap + hemopericardium → emergent cardiothoracic surgery (Hagan IRAD JAMA 2000)
    cta_chest_type_a_with_pericardial_blood
  • symptom
    BP/pulse differential between extremities + new hemodynamic instability → suspect dissection with branch-vessel malperfusion + possible tamponade overlay (ESC 2014; ACC/AHA 2022)
    pulse_or_bp_differential_with_hemodynamic_compromise
  • symptom
    Syncope at presentation in suspected aortic dissection — historically associated with tamponade per IRAD (Hagan JAMA 2000 PMID 10685714)
    syncope_in_dissection_pt_classic_for_tamponade

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher Type A mortality + worse surgical outcomes; bicuspid valve and connective tissue disorders shift age distribution younger (ACC/AHA 2022 PMID 36066317)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad AND signals tamponade physiology, malperfusion shock, or aortic rupture; goal SBP <120 with anti-impulse therapy once dissection confirmed (ACC/AHA 2022 Class I)
  • hrrequired
    vital • used at CONTEXT
    Goal HR <60 with esmolol BEFORE vasodilator added; reflex tachycardia from isolated vasodilator worsens dissection propagation (ACC/AHA 2022; Erbel ESC 2014)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Bedside TTE/TEE definitive for tamponade physiology + root dissection flap visualization; TEE preferred if hemodynamically unstable for transport (Class I; ACC/AHA 2022)
  • cta_chestrequired
    imaging • used at INITIAL_WORKUP
    Gold-standard definitive imaging for dissection extent, branch-vessel involvement, pericardial blood quantification — must be obtained when patient stable for transport (Hagan IRAD JAMA 2000 PMID 10685714)
  • connective_tissue_or_aortic_historyrequired
    history • used at CONTEXT
    Marfan, Loeys-Dietz, Ehlers-Danlos vascular type, bicuspid aortic valve, prior aortic surgery, hypertension history all modify pre-test probability + recurrence risk (ACC/AHA 2022)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline for contrast-related AKI risk + post-op AKI surveillance + dose-adjustment for any sedation/analgesia
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Baseline + serial for hemorrhagic loss + transfusion threshold; massive transfusion likely intraoperatively
  • inrrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy reversal pre-OR + tracking massive transfusion balance
  • d_dimer
    lab • used at INITIAL_WORKUP
    Highly sensitive (>97%) for acute aortic dissection if <500 ng/mL within 24h of symptom onset rules out with high NPV (ACC/AHA 2022 ADD-RS supplement)

12-phase flow (9)

  1. 1FRAME
    Type A dissection-related tamponade — DO NOT default to full pericardiocentesis; emergent cardiothoracic surgery is definitive; limited bridge drainage (≤50 mL) ONLY if hypotensive (ACC/AHA 2022; Hayashi Circ J 2012)
    inputs: sbp
    advance: dissection-context tamponade physiology suspected
  2. 2ENTRY
    Recognize Beck triad + tearing chest/back pain combination; activate aortic emergency pathway + simultaneous OR mobilization (ACC/AHA 2022 Class I)
    inputs: age
    advance: aortic dissection clinical pattern recognized
  3. 3CONTEXT
    Document connective tissue disease, prior aortic surgery, hypertension history, anticoagulation status; goals-of-care discussion with surgical-eligibility framing (ACC/AHA 2022)
    inputs: connective_tissue_or_aortic_history
    advance: dissection-context risk factors fully captured
  4. 4RED_FLAGS
    Tamponade obstructive shock + dissection-extension/malperfusion overlay (cerebral, coronary, mesenteric, renal, spinal, limb); periarrest physiology (ACC/AHA 2022; Trimarchi IRAD)
    inputs: sbp, hr
    advance: shock + malperfusion screened → OR mobilization in parallel with imaging
  5. 5INITIAL_WORKUP
    STAT echo (TTE → TEE if unstable), CTA chest if stable for transport, ECG, troponin, BMP, CBC, type & cross 6 units PRBC + 4 FFP, coags, lactate, ABG, baseline creatinine (ACC/AHA 2022 Class I; ESC 2014)
    inputs: echo, cta_chest, creatinine, hemoglobin, inr
    actions: panel.cardiac, panel.coag, panel.cbc
    advance: echo confirms tamponade + dissection flap + CTA confirms Type A extent
  6. 6DIFFERENTIAL
    Confirm Type A (ascending aorta involvement) vs Type B (descending only — does not cause tamponade); rule out concomitant rupture into pleural space; assess branch-vessel involvement (Hagan IRAD JAMA 2000 PMID 10685714)
    advance: Type A confirmed + dissection extent mapped
  7. 7TREATMENT
    Step 1 anti-impulse therapy with esmolol IV (HR target <60) BEFORE vasodilator (ACC/AHA 2022 Class I); Step 2 emergent cardiothoracic surgery activation; Step 3 LIMITED pericardiocentesis (≤50 mL) ONLY if hypotensive bridge per Hayashi Circ J 2012 + IRAD subgroup data — full drainage precipitates exsanguination (ACC/AHA 2022; Erbel ESC 2014); Step 4 OR for root repair + intraoperative pericardial drainage
    inputs: sbp
    advance: anti-impulse achieved + OR transfer initiated +/- limited bridge drainage performed
  8. 8DISPOSITION
    OR direct transfer for emergent cardiothoracic surgery (root replacement, valve-sparing root, Bentall, hemiarch/total arch per extent); cardiac surgery + anesthesia + perfusion teams mobilized in parallel (ACC/AHA 2022)
    advance: OR readiness confirmed + transport plan executed
  9. 9MONITORING
    Intraop TEE for root repair adequacy + pericardial decompression; post-op CCU/ICU surveillance for re-bleeding, malperfusion, AKI, neurologic outcome, paraplegia (spinal artery), graft integrity (ACC/AHA 2022)
    actions: panel.pleural
    advance: post-op stable + no re-bleeding × 48h + neurologic + renal + spinal cord baseline established