有心包膜積液的Type A，心跳一定要先壓到60才能降壓嗎？

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："Although the classic textbook description of AAS is of acute 'tearing' or 'ripping' pain, patients more commonly report the abrupt onset of severe 'sharp' or 'stabbing' pain in the chest or back (and sometimes abdomen), maximal at the start, that sometimes radiates." ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："the pain is described as severe in approximately 90% of patients and usually of sudden onset, with maximum intensity occurring at its inception." ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："The radiation and migration of pain often reflect the anatomic extension of the dissection." ↩︎

Hurst's the Heart. 15th ed. 原文："Pain may migrate inferiorly to the flank or pelvis as the dissection propagates distally." ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："Patients with mesenteric ischemia classically present with a soft abdomen and abdominal pain out of proportion to tenderness. This can also be observed with acute type A or B dissection." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："For each risk category, 1 point is assigned if ≥1 risk factors are present... An ADD-RS of 0 points is low risk; 1 point is moderate risk; and 2 to 3 points is high risk." ↩︎

Rogers AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation. 2011;123(20):2213-2218. PMID: 21555704. DOI: 10.1161/CIRCULATIONAHA.110.988568 原文："Of 2538 patients with acute aortic dissection, 2430 (95.7%) were identified by 1 or more of 12 proposed clinical risk markers. With the use of the ADD risk score, 108 patients (4.3%) were identified as low risk (ADD score 0) ... The clinical risk markers proposed in the 2010 thoracic aortic disease guidelines and their application as part of the ADD risk score comprise a highly sensitive clinical tool for the detection of acute aortic dissection." ↩︎

Ren S, et al. Diagnostic accuracy of the aortic dissection detection risk score alone or with D-dimer for acute aortic syndromes: Systematic review and meta-analysis. PLoS One. 2024;19(6):e0304401. PMID: 38905181. DOI: 10.1371/journal.pone.0304401 原文中的ADD-RS>0即≥1分。 原文："Summary sensitivities and specificities (95% credible interval) were: ADD-RS>0 94.6% (90%, 97.5%) and 34.7% (20.7%, 51.2%), ADD-RS>1 43.4% (31.2%, 57.1%) and 89.3% (80.4%, 94.8%)" ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："In patients with high probability (risk score 2 or 3) of aortic dissection, testing of D-dimers is not recommended." ↩︎

Tintinalli's Emergency Medicine. 9th ed. 原文："A normal d-dimer test can exclude pulmonary embolism in patients with low and moderate pretest probability" ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："Patients with high pretest probability or a positive D-dimer require imaging." ↩︎

Nazerian P, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018;137(3):250-258. PMID: 29030346. DOI: 10.1161/CIRCULATIONAHA.117.029457 原文："In 924 patients with ADD-RS ≤1/DD-, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1) and an efficiency of 49.9% (95% CI, 47.7-52.2)" 另見摘要："A total of 1850 patients were analyzed." 以及 "DD was considered negative (DD-) if <500 ng/mL." ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. 原文："Normally, veins will compress easily while arteries can be difficult to compress." ↩︎

Hurst's the Heart. 15th ed. 原文："The false lumen may terminate at any point along the length of the aorta or in the iliac or femoral arteries, and there are sometimes multiple flaps and several sites of reentry." ↩︎

LePage MA, et al. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001;177(1):207-211. 原文："The beak sign and a larger cross-sectional area were the most useful indicators of the false lumen for both acute and chronic dissections. Features generally indicative of the true lumen included outer wall calcification and eccentric flap calcification. In cases showing one lumen wrapping around the other lumen in the aortic arch, the inner lumen was invariably the true lumen." ↩︎ ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："If the false lumen is completely thrombosed, it demonstrates low attenuation. The false lumen usually has slower flow and a larger diameter than the true lumen." ↩︎

Hurst's the Heart. 14th ed. Fig. 22-4圖說（引自LePage 2001）。 原文："The outer false lumen (F) wraps around the true lumen (T). ... Eccentric flap calcification is present along the true lumen side of the flap." ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："Distention of the false lumen with blood causes the intimal flap to compress the true lumen and narrow its caliber and may lead to malperfusion syndromes." ↩︎

Hurst's the Heart. 15th ed. 原文："the dissection usually has spiral morphology, leaving some aortic branches supplied by the true lumen and others in continuity with the false lumen." ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："A focused TTE at the emergency department, if available, is recommended to assess pericardial effusion, wall motion abnormalities, aortic regurgitation, and aortic diameters." ↩︎

Rosen's Emergency Medicine. 10th ed. 主動脈剝離章。 原文："dissection generally requires expeditious surgical repair due to progressive increasing risk of multiple complications, including rupture into the pericardial space" ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："Cardiac tamponade, which occurs in 8% to 31% of acute type A dissections, is one of the most common mechanisms of death in patients with dissection ... Patients with tamponade ... have double the inhospital mortality rate as those without tamponade (54% versus 25%)." ↩︎

Braunwald's Heart Disease，心包膜疾病章，cardiac tamponade段落。 原文："Several echocardiographic findings indicate that tamponade is severe enough to cause hemodynamic compromise. ... These include early diastolic collapse of the right ventricle, late diastolic indentation or collapse of the right atrium ... Early diastolic RV collapse ... and late diastolic RA collapse ... are signs that usually first appear relatively early during tamponade, when pericardial pressure transiently exceeds intracavitary pressure. ... Distention of the inferior vena cava that does not diminish with inspiration is an important confirmatory finding." ↩︎ ↩︎ ↩︎ ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. 原文："Right ventricular diastolic collapse (Figure 22-106), right atrial collapse during systole (Figure 22-107), and dilated inferior vena cava with lack of inspiratory collapse (Figure 22-108) are seen with cardiac tamponade." Ma and Mateer對RA寫的是during systole，Braunwald寫late diastolic；本文正文採Braunwald。 ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. Figure 6-35圖說。 原文："The IVC normally collapses >50% with inspiration or sniffing (A, B), but has no inspiratory collapse when central venous pressure is elevated (C)." ↩︎

ASE's Comprehensive Echocardiography. 原文："An IVC diameter less than 2.1 cm that collapses more than 50% with a sniff suggests a normal RA pressure of 3 mm Hg (range is 0 to 5 mm Hg), whereas an IVC diameter greater than 2.1 cm that collapses less than 50% with a sniff suggests a high RA pressure of 15 mm Hg (range is 10 to 20 mm Hg)." ↩︎

ASE's Comprehensive Echocardiography. Inferior Vena Cava Plethora段落。 原文："with associated minimal (<50%) respiratory change in size is considered a sensitive sign of cardiac tamponade physiology, reflecting the elevated intrapericardial pressure transmitted to the right heart chambers. ... Because a dilated IVC is seen in many other conditions, IVC plethora is considered a nonspecific sign of cardiac tamponade. However, its presence in the setting of a patient with a moderate to large pericardial effusion is helpful in implying that the pericardial fluid has hemodynamic import." ↩︎ ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："US examination may demonstrate an unexplained pericardial effusion, a dilated aortic root (>4 cm), aortic insufficiency, and/or a linear echogenic flap in the descending aorta." ↩︎ ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. 原文："These changes may be difficult to appreciate in real-time B-mode (2D) imaging but will be more apparent if the video is frozen and rolled backward slowly." ↩︎

ASE's Comprehensive Echocardiography. Cardiac tamponade段落。 原文："The exact timing of diastolic right ventricular collapse can also be demonstrated by M-mode echocardiography" ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. Figure 6-42圖說。 原文："M-mode image demonstrating right ventricular diastolic collapse. In a parasternal long-axis view, the M-mode cursor is directed through the right ventricular free wall and the mitral valve. ... The free wall of the right ventricle collapses toward the mitral valve as the valve opens during diastole." ↩︎

Mazzolai L, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024;45(36):3538-3700. PMID: 39210722. DOI: 10.1093/eurheartj/ehae179 原文："its diagnostic accuracy for AAS is limited (sensitivity: 78%–100% for type A, 31%–55% for type B)" ↩︎

Ma and Mateer's Emergency Ultrasound. 3rd ed. 原文："Transthoracic ultrasound is very useful if an abnormality is seen, but not sensitive for detecting thoracic aortic dissection, so it should not be used to rule out this diagnosis." ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："In unstable patients who cannot be transferred to CCT, TOE is recommended for diagnosis"（I-B） ↩︎

Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022;146(24):e334-e482. PMID: 36322642. DOI: 10.1161/CIR.0000000000001106 原文："In patients with AAS, initial management should include intravenous vasodilators if the BP is not well controlled after initiation of intravenous beta-blocker therapy." ↩︎ ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："If the BP target is not reached after initiating beta-blockers, i.v. vasodilators such as nitrates or dihydropyridine CCBs (e.g. nicardipine) can be administered concomitantly with rate-controlling agents first to avoid reflex tachycardia." ↩︎ ↩︎

Textbook of Critical Care. 6th ed. Aortic dissection. 原文："Pure vasodilator drugs should be avoided as an initial treatment, because reflex tachycardia and increased cardiac contractility may actually increase the rate of change in aortic pressure and, at least theoretically, exacerbate the dissection process." ↩︎ ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："These measures should commence immediately while the patient is undergoing diagnostic evaluation." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："Patients with AAS should be treated to an SBP <120 mm Hg or to lowest BP that maintains adequate end-organ perfusion, as well as to a target heart rate of 60 to 80 bpm."（1 C-LD） ↩︎ ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："In patients with AAS, immediate anti-impulse treatment targeting SBP <120 mmHg and heart rate ≤60 b.p.m. is recommended."（I-B） ↩︎

Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. 原文："The therapeutic goal in acute aortic dissection is a systolic blood pressure between 100 and 120 mm Hg and a heart rate ≤60 beats/min, ideally within the first hour of presentation." ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："This is accomplished by decreasing the force of cardiac contraction and resulting aortic sheer forces, and driving the heart rate down to 60 beats per minute or less. Acceleration of aortic blood flow, dP/dt, is minimized while maintaining blood pressure in the low normal range." ↩︎

Mattu A, et al. Cardiovascular Emergencies. ACEP. 原文："Like nitroprusside, nitroglycerin is a nitric oxide generator that induces both arterial and venous dilation. However, unlike nitroprusside, venodilation predominates. This means that nitroglycerin is not an ideal drug for the purpose of lowering arterial blood pressure." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："There are no randomized studies that have evaluated different medical treatments in the treatment of AAS, although extensive clinical experience has established the current standard of anti-impulse therapy." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："...early mortality of 1% to 2% per hour after symptom onset." ↩︎

Harris KM, et al. Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. JAMA Cardiol. 2022;7(10):1009-1015. PMID: 36001309. Hirst的505例為本文轉引（原始文獻：Hirst AE Jr, et al. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37(3):217-279）。 原文："In the series by Hirst et al from the 1950s, mortality was estimated at 21% in the first 24 hours and 37% in the first 48 hours." ↩︎

Harris KM, et al. Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. JAMA Cardiol. 2022;7(10):1009-1015. PMID: 36001309. 從到院起算；內科組非隨機分組。全部與手術組的「換算每小時」是本文自行換算。 原文："A total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group ... and 480 (8.6%) in the medical group ... mean [SD] age, 70.9 [14.7] years ... Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%." 另見："Early data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours." 以及 "Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81)." ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："In cases of malperfusion, higher BP could be tolerated to optimize perfusion to the threatened region." ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："Invasive monitoring with an arterial line and continuous three-lead ECG recording, as well as admission to an intensive care unit, is recommended."（I-B） ↩︎ ↩︎

Rosen's Emergency Medicine: Concepts and Clinical Practice. 10th ed. 來源只講半衰期短、好調整，沒有針對PEF；「PEF病人最好用」是本文的推論。 原文："Favored agents include esmolol infusion due to its short 9-minute half-life and titratability, or metoprolol or labetalol if esmolol is not readily available." ↩︎ ↩︎

Tintinalli's Emergency Medicine. 9th ed. 原文："β-Blockade is ideal, and short-acting β-blockers such as esmolol or labetalol are preferred over long-acting β-blockers." ↩︎

Braunwald's Heart Disease，談β-blocker相對禁忌症的段落，不是針對主動脈剝離。 原文："Because the hemodynamic effects of this drug (half-life of 9 minutes) disappear in less than 30 minutes, it offers an advantage over longer-acting agents when the risk for complications with a beta blocker is relatively high." ↩︎

DailyMed: Brevibloc (esmolol hydrochloride) injection. U.S. National Library of Medicine. 仿單的適應症是圍手術期心搏過速與高血壓，不是主動脈剝離。 原文："Loading dose: 500 mcg per kg over 1 minute for gradual control (1 mg per kg over 30 seconds for immediate control) ... Then 50 mcg per kg per min for gradual control (150 mcg per kg per minute for immediate control) ... For the treatment of hypertension, higher maintenance infusion dosages (250-300 mcg per kg per min) may be required. ... Decrease of dose or termination of infusion reverses hypotension, usually within 30 minutes." ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："Intravenous beta blockade (labetalol as a first choice due to its alpha- and beta-blocking properties) is generally accepted as the best option." ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："Labetalol is given at an initial IV dose of 20 mg over 2 minutes and then at 40 to 80 mg every 10 minutes (maximum dose, 300 mg) until the desired response is achieved." ↩︎

DailyMed: Labetalol hydrochloride injection (Hospira). U.S. National Library of Medicine. 原文："Additional injections of 40 mg or 80 mg can be given at 10 minute intervals until a desired supine blood pressure is achieved or a total of 300 mg labetalol HCl has been injected. ... The diluted solution should be administered at a rate of 2 mL/min to deliver 2 mg/min." ↩︎

Tintinalli's Emergency Medicine. 9th ed.，高血壓急症用藥表。 原文："Always use β-blocker prior to vasodilators" ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："Other IV medications for severe hypertension include nicardipine (5 mg/hr, can be increased to a maximum of 15 mg/hr)." ↩︎

DailyMed: Cardene IV (nicardipine hydrochloride) injection. U.S. National Library of Medicine. 原文："In a patient not receiving oral nicardipine, initiate therapy at 5 mg/hr. Increase the infusion rate by 2.5 mg/hr every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 15 mg/hr until desired blood pressure reduction is achieved." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："Caution should be used in patients with contraindications to beta blockers (eg, acute AR, heart block, or bradycardia). In patients who are intolerant to beta blockers, intravenous non-dihydropyridine calcium channel blockers (ie, verapamil or diltiazem) are typically used for initial treatment." ↩︎

Tintinalli's Emergency Medicine. 9th ed. 原文："Although β-blockers are commonly used in aortic dissection, avoid these in acute aortic regurgitation because they block the compensatory tachycardia that is critical in maintaining cardiac output." ↩︎

Hurst's the Heart. 14th ed. 原文："Beta-blockers should be avoided in acute AR because they prolong diastole and may worsen AR." ↩︎

Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed.，外傷性主動脈損傷（traumatic aortic injuries）段落。 原文："A vasodilating calcium channel blocker such as nicardipine or clevidipine is recommended over sodium nitroprusside." ↩︎

Tintinalli's Emergency Medicine. 9th ed.，高血壓急症用藥表。 原文："cyanide and thiocyanate toxicity in patients with reduced renal function or therapy >24–48 h" ↩︎

DailyMed: Sodium nitroprusside injection (Xiromed) 美國仿單，boxed warning。 原文："Sodium Nitroprusside Injection can cause precipitous decreases in blood pressure ... In patients not properly monitored, these decreases can lead to irreversible ischemic injuries or death. ... sodium nitroprusside gives rise to important quantities of cyanide ion, which can reach toxic, potentially lethal levels" ↩︎

Ulici A, et al. Clevidipine versus sodium nitroprusside in acute aortic dissection: a retrospective chart review. Am J Emerg Med. 2017;35(10):1514-1518. PMID: 28669696。單中心回溯、n=14，比較對象是clevidipine，不是nicardipine。 原文："Clevidipine administration during initial medical management of aortic dissection showed similar efficacy compared to SNP when used as adjunct therapy to esmolol." ↩︎

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. 原文："Intravenous opiates are particularly efficacious in this situation. Intravenous nonsteroidal anti-inflammatory drugs, such as ketorolac, may not be suitable because of the risk of inducing hypertension as well as adverse renal effects." ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："Fentanyl benefits from a short half-life allowing titratability and relatively minimal secondary decrease in blood pressure." ↩︎

Braunwald's Heart Disease. Pericardial Diseases. 原文："The compensatory response to a hemodynamically significant effusion includes increased adrenergic tone and parasympathetic withdrawal. The resultant tachycardia and increased contractility maintain the cardiac output and blood pressure for a period of time. ... Patients who cannot mount a normal adrenergic response (e.g., those receiving beta blockers) are more susceptible to the effects of an effusion." ↩︎ ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："Hypotension should elicit an immediate search for potentially reversible causes such as pericardial tamponade or internal hemorrhage. In addition to any temporizing interventions such as pericardiocentesis, blood pressure may be supported with crystalloid infusion and vasopressors to provide adequate perfusion of vital organs, targeting a mean arterial pressure of 65 mm Hg. Norepinephrine or phenylephrine infusions are preferred to maximize peripheral vasoconstriction and minimize myocardial stimulation with resulting sheer stress. Antiadrenergic infusions should be stopped." ↩︎ ↩︎

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. 原文："For potential cardiac arrest from pericardial tamponade, consider an emergency pericardial puncture as a temporary life-saving measure before transferring to the operating room." ↩︎ ↩︎

Textbook of Critical Care. 6th ed. 心包膜填塞的處置段落。 原文："Intravenous fluid administration is the best treatment option before and during drainage. • Intravenous administration of diuretics is contraindicated and could be fatal in patients on the edge of their compensatory mechanism in tamponade." ↩︎

Tintinalli's Emergency Medicine. 9th ed. 原文："The reduced cardiac output is offset by the increase in heart rate and increase in systemic vascular resistance. Often, the only clinical finding of pericardial tamponade is sinus tachycardia." ↩︎ ↩︎

Braunwald's Heart Disease，右心室梗塞段落。 原文："Because of their ability to reduce preload, medications routinely prescribed for LV infarction may produce profound hypotension in patients with RV infarction. Specifically, nitrates, morphine, and diuretics should be avoided." ↩︎ ↩︎

Tintinalli's Emergency Medicine. 9th ed. 主動脈剝離段落。 原文："Pain control with opioids helps decrease sympathetic tone." ↩︎

Textbook of Critical Care. 6th ed. 鎮痛鎮靜章。 原文："Morphine can cause hypotension by triggering the release of histamine and by the ablation of pain-mediated sympathetic stimulation." ↩︎

Braunwald's Heart Disease. Diseases of the Aorta. 原文："Pericardiocentesis for acute hemopericardium in patients with dissection can result in recurrent bleeding and acute hemodynamic collapse, especially if a larger volume of fluid is removed and increased BP leads to further brisk bleeding into the pericardial space. Therefore, in a relatively stable patient with acute type A dissection and cardiac tamponade, the risks associated with pericardiocentesis probably outweigh its benefits." "However, for patients who will not survive until surgery, pericardiocentesis with aspiration of only enough pericardial fluid to stabilize the patient before surgery may be lifesaving and should be considered a treatment option in this setting." ↩︎

Rosen's Emergency Medicine. 10th ed. 原文："Once the catheter is inserted, 5 to 10 mL of hemopericardium can be aspirated with close observation of the resulting hemodynamics. Aspiration can be repeated as needed to attain a systolic blood pressure of 80 to 90 mm Hg." 同段前文："Controlled catheter drainage with a pigtail catheter can be performed with ED ultrasound guidance to temporize and allow time to prepare for definitive operative care." ↩︎

同上（Lin CY, et al. PLoS One 2020），方法段。 原文："By spreading the tips of the hemostatic forceps, a 2–4 cm 2 pericardiotomy was created. After evacuation of the hemopericardium and stabilization of hemodynamics, the xiphoid region was packed with gauze to prevent persistent bleeding from the pericardial cavity, and further aortic repair procedures were implemented immediately. The E-SXP procedure was usually completed in 3 min." ↩︎ ↩︎ ↩︎

Lin CY, et al. Surgical rescues for critical hemopericardium complicated by acute type A aortic dissection: Emergent subxiphoid pericardiotomy or cardiopulmonary bypass first? PLoS One. 2020;15(3):e0229648. PMID: 32119707. DOI: 10.1371/journal.pone.0229648 原文："According to preoperative computed tomography, hemopericardium was found in 191 patients (32.6%), 150 were stabilized with medical treatment, and 41 underwent surgical rescues for critical hemodynamics. ... The average systolic blood pressure was 62.4 ± 13.3 mmHg and 67.1 ± 13.1 mmHg in the E-SXP and E-CPB groups, respectively. ... The in-hospital mortality was similar (30.8% versus 33.3%, P = 0.865) in the two groups." 另見摘要："Between January 2007 and March 2019, 586 consecutive patients underwent ATAAD repair at our institution." 以及 "emergent subxiphoid pericardiotomy (E-SXP group, n = 26, 63.4%) or emergent cardiopulmonary bypass (E-CPB group, n = 15, 36.6%)" ↩︎ ↩︎

同上（Lin CY, et al. PLoS One 2020），討論段。 原文："an inexperienced echocardiography-guided pericardiocentesis may be less efficient and reliable compared to surgical rescue procedures. As a simplified technique, the E-SXP can decompress the pericardial cavity immediately and evacuate the hemopericardium. However, this procedure revealed similar potential risks of inducing large fluctuations in blood pressure and rupture of the dissected aorta. Even with a limited drainage with gauze packing at the subxiphoid wound, which mimics a controlled pericardiocentesis, there were still six patients who underwent concomitant E-CPB due to continuous bleeding from the aorta. Three of these patients died ... we suggest that strict control of blood pressure/heart rate is mandatory when performing E-SXP in patients with ATAAD-complicated hemopericardium. Furthermore, E-SXP should be avoided for patients with signs of contained aortic rupture according to preoperative image studies, and a prepared CPB machine with blood recyclers should be on standby if possible." ↩︎ ↩︎ ↩︎

同上（Lin CY, et al. PLoS One 2020），研究限制。 原文："First, with a retrospective and non-randomized control design with small sample size, bias might exist that influenced the homogeneity and power of statistical analyses of the study groups. Second, the rescue procedure was chosen by individual physicians based on a clinical judgment" ↩︎

Tintinalli's Emergency Medicine. 9th ed. Table: General Indications and Contraindications for Extracorporeal CPR。 原文（禁忌欄）："Suspect aortic dissection or severe aortic regurgitation; traumatic cardiac arrest" ↩︎

Emergency Echocardiography. Echocardiography before extracorporeal membrane oxygenation commencement段落。 原文："Conditions that preclude the use of ECMO can also be revealed by echocardiography, such as aortic dissection, atherosclerotic disease in the aorta, tricuspid valve stenosis or tricuspid valve (TV) replacement" ↩︎

Ohbe H, et al. Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study. Resuscitation. 2020;156:237-243. PMID: 32800864. DOI: 10.1016/j.resuscitation.2020.08.001 原文："Acute aortic dissection (AAD) has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). ... We identified 398 AAD patients with ECPR ... In-hospital mortality was 98% in AAD patients with ECPR ... Seven AAD patients survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge." 另見："Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018" 以及結論 "ECPR successfully improved outcomes and/or facilitated surgery for a small number of AAD patients with refractory cardiac arrest" ↩︎ ↩︎