- Assess vital signs.
- Place 2 large bore intravenous (IV) lines.
- Provide supplemental oxygen if hypoxic.
- Monitor heart rate and control blood pressure.
- Manage pain.
- Notify the blood bank to prepare blood products.
- Correct coagulopathy.
- Order CT angiogram of chest / abdomen / pelvis with and without contrast.
- Expedite expert consultation with an aortic specialist (the type of specialist is institution dependent).
Intramural hematoma (IMH) is a type of acute aortic syndrome (AAS) where there is bleeding into the wall of the aorta. AAS is a group of conditions that includes acute aortic dissection (AAD), penetrating aortic ulcer (PAU), and IMH. IMH accounts for 10%-30% of all AASs. Often, IMH can be confused with AAD; however, in IMH, there is bleeding contained in the wall of the aorta without formation of a dissection flap and without production of true and false lumens.
The rate of complications is high, and complications are often deadly. Look for signs / symptoms related to complications, such as pericardial effusion / tamponade, neurologic deficits, acute myocardial infarction (MI), rupture / dissection, etc.
IMH is classified into type A (ascending aorta) and type B (not involving the ascending aorta but including the aortic arch). Type A IMH has a higher frequency of complications including dissection, rupture, and death.
Diagnosis can be difficult and requires high clinical suspicion. If suspected, confirm quickly and proceed rapidly to treatment.
When to suspect acute aortic syndrome or intramural hematoma:
- Typical pain, aka "aortic pain" – Present in 90% of patients. All AASs have similar presentations. Described as abrupt or sudden, excruciating anterior or posterior chest pain. Pain may radiate to the back, neck, or chest, and it may extend to the low back or limbs. Pain may be qualified as ripping, tearing, or stabbing.
- Tachycardia – This can be due to pain, acute aortic regurgitation, or pericardial tamponade.
- Hypertension – Most commonly, patients are hypertensive at presentation.
- Hypotension is also possible and is an ominous sign of complications such as myocardial ischemia, pericardial tamponade, aortic insufficiency, or rupture. Blood pressure should be evaluated in the bilateral upper extremities for symmetry.
- Incongruous tissue perfusion – Poor perfusion despite hypertension can be a sign of aortic branch occlusion, a known complication of IMH / AAS.
- Chest pain with neurologic deficits – Chest pain plus a new or evolving neurologic deficit can be a sign of AAD.
- Rarer presentations include syncope, anterior spinal pain syndrome, hoarseness, acute renal insufficiency, and acute neurologic deficits.
