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ICOM-Cardio > Cardio- Clinical- Vascular Emergencies- Trainer > Flashcards

Cardio- Clinical- Vascular Emergencies- Trainer Flashcards

1
Q

Most of the time in acute onset arterial occlusion, it is from a resulting throumbus/emboli?

A

emboli

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2
Q

Emboli most commonly come from which part of the heart?

A

80% of emboli from left ventricle, typically after MI

Only 10% from left atrium; LA clots usually from Afib, go to brain

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3
Q

Clots from AFIB usually come from which part of heart and normally go where?

A

left atrium and to the brain

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4
Q

What are some symptoms of peripheral occlusion?

A

Pale and mottled, cyanotic, cold ; absent pulses and cap refill; loss of soft touch

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5
Q

What is blue toe syndrome?

A

ACUTE PERIPHERAL ISCHEMIA DUE TO SMALL-VESSEL OCCLUSION (artery) from microemboli

Abrupt onset of small painful area on affected digit.

Affected area is tender, cool, and cyanotic.

Asymmetric distribution.

Livedo reticularis may be present.

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6
Q

What is the condition of acute peripheral ischemia that gives more time for repair and salvage and indicates the extremity is viable?

A

neurology intact and pulses

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7
Q

Which factors indicated minutes (threatened) before loss of limb with acute peripheral occlusion?

A

loss of sensation

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8
Q

What condtions would indicate the death of a limb from acute onset arterial occlusion?

A

loss of sensation and motor

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9
Q

Blue toe syndrome includes the loss of which 3 things?

A

sensation/pulse/color

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10
Q

Which occlusion is most likely acute and which is most likely gradual (intermittent claudication)?

A

Acute= emboli

Thrombus = gradual (intermittent claudication = atherosclerosis)

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11
Q

Many times you can get an embolic showering from .

A

proximal aorta -dissect, form clot, shower distally

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12
Q

What are the 6 p’s of acute arterial or limb ischemia?

A

Pain (claudication), Pallor, Paresthesia, Paralysis, Pulseless (late!),Poikilothermia=cold (in order of occurrence)

The pain is often “POOP”

pain of of proportion

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13
Q

What is the study of choice for diagnosing acute arterial occlusion?

A

. Duplex arterial ultrasonography ( use doppler)

  • uses Ankle-brachial index: noninvasive and can be done in an office setting with Doppler
  • then probably angiography
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14
Q

Extracranial emboli (mostly lower extremity) represent 11.5% of events in atrial fibrillation

A

nonvalvular

if valves involved (they can go peripherally)

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15
Q

AFIB nonvalvular extracranial events (occlusions) occured most commonly in which three areas:

A

A. Lower extremities (58%)

B. Visceral-mesenteric circulation (31%)

C. Upper extremities (11%)

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16
Q

How to use the anke-brachial index:

A

take highest ankle pressure (of side affected, or both sides) at the dorsalis pedis or posterior tibialis and you will also take the same side highest arm pressure as well

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17
Q

How do we calculate anke-brachial index? And what are the numerical categories?

A

Lower extremity systolic pressure/ highest brachial artery systolic pressure

>0.90 = normal

  1. 71-0.90 = Mild obstruction/disruption
  2. 41-0.70 = Moderate disruption
  3. 00-0.40 = Severe disruption
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18
Q

How to treat acute peripheral arterial occlusion?

A

Emergent! -need surgical consult

Safety net

Heparin

pain control

fogarty embolectomy w/o angiography

Not indicated:

be careful of thrombolytics (microemboli)

angiogram (increases viscosity)

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19
Q

What is a fogarty catheter?

A

remove fresh emboli in the arterial system. It consists of a hollow tube with an inflatable balloon attached to its tip. The catheter is inserted into the blood vessel through a clot, pull clot out

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20
Q

peripheral arterial aneurysms generally occur in which two arteries? Most likely due to which pathology?

A

femoral and popliteal; HTN

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21
Q

Which population has a higher risk of peripheral arterial aneurysms?

A

50 yr old men

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22
Q

Other areas other than popliteal and femoral artery for peripheral arterial aneurysms?

A

Splenic>>Hepatic artery>>>SMA

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23
Q

60% of visceral aneurysms occur where?

A

the splenic artery (women 4:1)

pregnancy may put you at increased risk

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24
Q

What are the symptoms or a splenic artery aneurysm:

A

POOP - pain out of proportion

GI bleed,

intestinal angina (especially after eating)

diffuse/severe pain

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25
Q

How to diagnose peripheral arterial aneurysms (mostly involving splenic artery):

A

CT with contrast is the study of choice

also labs: metabolic acidosis, elevated lactate, elevated WBC with stress (non-infection)

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26
Q

What causes pseudoaneurysms:

A

trauma

which can include post operative after angioplasty

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27
Q

In order, which is the most common origin of distal arterial emboli out of left ventricle, left artium, and proximal aorta

A

left ventricle>> proximal aorta>> left atrium

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28
Q

What is the best next step in management of acute arterial occlusion?

A

As the diagnosis is clinical- vascular surgery consult would be the best next step out of the options above.

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29
Q

After safety net and vascular surgery consult for AAA, what would be the next step?

A

order blood products

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30
Q

What is the difference between men and women in AAA presentation?

A

Women present later

31
Q

In acute distal arterial embolism, is pulselessness of affected extremity and early or late sign?

A

late, not likely keep the limb

32
Q

Concerning an AAA, a plain film X ray can show you aneurysm calcification but cannot show you which concerning events?

A

dissection, free fluid, expansion

33
Q

Which is the best study if suspected AAA?

A

Bedside ultrasound

34
Q

What is key for any presentation of AAA?

A

family history

35
Q

% of AAA rupture patients are <50 and nonsmomkers

A

50%

36
Q

Concerning AAA, do men or women rupture more often?

A

Women tend to delay presentation and rupture more often than men

37
Q

What are some risks for AAA?

A

family history, elderly, history of arterial or peripheral vascuar disease, HTN, and connective tissues diseases

38
Q

What is the suggested management of asympyomatic AAA up until 4.5 cm?

A

conservative until around 5 cm, then surgery, even if asymptomatic

39
Q

What is the suggested treatment protocol for AAA if >3 cm, actively having pain and tenderness?

A

symptoms, tenderness, abnormality- over 3 cm means impending rupture or rupturing AAA until proven otherwise

40
Q

What is indicated in this image?

A

AAA rupture, fluid, and clotting

41
Q

What is the next step if AAA rupture?

A
  • start fluid resuscitation (have the blood ready)
  • massive transfusion protocol 1:1:1 (packed RBC, FFP, platelets) in succession
42
Q

If a patient has a rupturing AAA and HTN, how does this affect treatment

A

no aggressive treatment of HTN because she will progressively become more hypotensive as she bleeds out

  • antihypertensives may worsen situation
  • this varies from a dissection that has not ruptured
43
Q

Critical steps for suspected AAA rupture treatment?

A
  1. Safety net (IV, O2, crash cart)
  2. call vascular surgeon
  3. type and cross match for 10 U (massive transfusion protocol including packed RBC:FFP:platelets (1:1:1)
44
Q

What is the mortality rate of ruptured AAA?

A
  • Approaches 100% unless surgery immediately; clinical diagnosis
  • 40% even with surgery
45
Q

What type of surgery is performed for AAA that has not ruptured, sometimes even if unstable?

A

endovascular coil (creates a channel and bypasses rupture), however, very selective population (better for stable aneurysm)

46
Q

What are some AAA complications (4) after repair?

A
  1. Aortoenteric fistula
  2. Graft infection (mycotic-fungal)
  3. Pseudoaneurysm
  4. Endovascular repair leak
47
Q

What should be considered in any patient with a GI bleed and history of AAA repair, occurs most often in distal duodenum, and needs a vascular surgeon immediately?

A

aortoenteric fistula

48
Q

Where does an aortoenteric fistula commonly occur?

A

distal duodenum

49
Q

Fever, pain, history of AAA repair, think:

A

graft infection (clot can form around the graft, can be infected with bacteria or fungus (mycotic)).

50
Q

What does a pseudoaneurysm AAA complication entail:

A

= blood outside the wall collected in tissue and is pulsatile; involves outer layers

-• hematoma is completely outside the vessel, but can still be pulsatile as is next to aorta

51
Q
A

A. AE fistula not common with AAA but with AAA repair

B. Mesenteric ischemia would indicate emboli or thrombi

C. Rupture

D. Renal artery compromise (most AAA rupture distal to renal artery)

E. limb ischemia (yes, this can be caused by AAA but not most common)

52
Q
A

A. any symptoms or exam findings greater than 3 cm (are the indications for AAA repair)

B. Size >or equal to 3.5 (need more info)

C. HTN (is a risk factor but more info needed)

D. Past history of MI, high cholesterol, tobacco use (more so risk factors for peripheral vascular dz)

E. Anemia (possible complication)

53
Q
A

A. CT angiogram is useful

B. Blood replacement if rupture

C. Blood pressure management (not if high, give blood products if low)

D. Vascular consultation is by far the best next step

E. Duplex ultrasound (not indicated, more likely POCUS or bedside ultrasound)

54
Q

What is on the top of your differential with “ripping” or “tearing” sound/pain, pain radiates to back, migrates to upper abdomen, diastolic murmur, muffled heart sounds, pulse differences in LUE vs RUE, LUQ tenderness?

A

thoracic aortic dissection

55
Q

How many differentials for each patient?

A

3-5

56
Q

What is the best study for suspected thoracic aortic dissection?

A

transesophogeal echo (TEE) followed by POCUS

57
Q

What are some potential findings with bedside ultrasound of a suspected thoracic aortic dissection?

A
  1. Acute, maximal pain at onset, ripping/tearing, rad to back, migratory; syncope, paralysis (carotid involvement to brain to cause stroke); 3:1 Male:Female with age ≥40 yo
  2. Aortic regurgitation due to dilation of aortic root (diastolic murmur)
  3. Hypotensive, normotensive, or hypertensive (typical)
  4. S&S of tamponade (muffled heart sounds)
  5. tachychardia, SOB
58
Q
A

Global STEMI (possible dissection)

-anterolateral STEMI (st elevation in V2,V3,V4 and also in V1, AVL, V5,and V6) with reciprocal changes in inferior leads (II,III,aVF)

remember high lateral is I and AVL

low lateral is V5 and V6

interior is V2,V3

59
Q

What can be seen from this chest X-ray and how sensitive is it?

A
  • blunting of aortic knob (left apical cap)
  • Widening of the mediastinum -

Left-sided effusion (small) = left hemothorax (blunting of left costophrenic angle)

  • Mild shift of the trachea to the right
  • Left mainstem can be depressed (not in this case) with elevated right mainstem

Chest XR is not sensitive

60
Q

Why is it more common to have left sided pleural effusions in thoracic aortic dissections?

A

aorta descends to the left thorax?

61
Q

What is the gold standard for TEE workup?

A

CT -angio unless TEE available (sensitive and specific)

MRI is better than both but not practical or fast enough

note: image on left is CT and right is aortaogram

62
Q

What are the steps in treateing thoracic aortic aneurysm?

A
  • lower BP to lower shearing forces
  • pain control
  • Standford classification
63
Q

What is the two types of Standford classification for thoracic aortic dissection?

A
  1. Type A = “A”scending and needs “A” Surgeon! Any involvement of ascending aorta • Mortality: 54% without surgery; 26% with surgery
  2. Type B = isolated descending (medical management, 1/3 will need surgery anyway, 11% mortality)
64
Q

What are the medications used to treat thoracic aortic dissection?

A

BBlockers (mainstay, can be sole medication)

    • esmolol: titratable, short acting; d/t selective B1 block typically need another antihypertensive (eg. nitroprusside)
      - as esmolol is a B1 receptor antagonist, must monitor BP as esmolol is not always effective at decreasing BP
65
Q

As concerning treatment for thoracic aortic dissection, why do we start esmolol first, before antihypertensive?

A

if a antihypertensive is given first, could get relex tachycardia (not good as most likely already tachycardic)

66
Q

What type of medicaton is labetalol and how is it recommended for medical management of thoracic aortic dissection?

A

non-selective BB and alpha1 blocker; IV only

-it is 7:1 more active on B receptor than A, so recommended treatment

less titratable, usually administered bolus

67
Q

Which nitro is used more often as treatment for thoracic aortic dissection? Nitroglycerin or nitroprusside

A

nitroglycerine, (nitroprusside not used as often)

68
Q

As concerning medical management for thoracic aortic dissection if BBlockers not tolerated?

A

nicardopine, which is a great peripheral vascular dilator

69
Q

Which non pharmacological treatment is becoming more common for treating thoracic aortic dissection?

A

endovascular repair (coil)

70
Q
A

Aortic reguritation (murmur)

71
Q
A

D. TEE

(if TEE is not listed, CT angio is next best choice)

72
Q
A

E. Labetalol, best coverage, non-selective, and does not require another medication to treat HTN

-esmolol would only treat tachycardia

73
Q
A

ICOM-Cardio (32 decks)

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