Case 18- AAA Flashcards
AAA screening outcomes
<3cm- normal no further action required
3-4.4cm- rescan in 12 months
4.5-5.4cm- rescan in 3 months
>5.5cm- refers within 2 weeks to vascular surgery.
Investigations for DIC
FBC- thrombocytopenia
D dimer- raised
Clotting profile- prolonged APTT, prothrombin and bleeding time
Blood film- schistocytes (microangiographic haemolytic anaemia)
Older male presents with renal colic
Treat as ruptured AAA
Ischaemic bowel disease
Encompasses a heterogenous group of disorders caused by acute or chronic processes arising from occlusive or non occlusive aetiologies, resulting in decreased blood flow to the GI tract
Acute mesenteric ischameia
Typically an embolus resulting in occlusion of an artery which supplies the small bowel. Severe, sudden abdominal pain and very little exam findings. Suspect in a patient with known/ new AF.
Chronic mesenteric ischaemia
Colicky, intermittent abdominal pain. Think of as intestinal angina
Ischaemic colitis
An acute but transient (non-fulminant such as acute mesenteric ischaemia) compromise in blood flow to the large bowel- doesn’t cause tissue gangrene. Can occur after abdominal surgery
Sx of ischaemic bowel disease
Abdominal pain, melaena, haematochezia, diarrhoea, abdominal tenderness, weight loss, abdominal bruit, signs of shock
Differentials for ischaemic bowel disease
Infective colitis, ulcerative colitis, large bowel obstruction, acute pancreatitis, gastroenteritis
Aspirin and the coagulation profile
Only prolongs the bleeding time. All else normal
Waterhouse Friderichsen syndrome
Adrenal infarcts which lead to adrenal insufficiency during DIC
Acute limb ischaemia
Sudden lack of blood flow to a limb. Caused by embolism or thrombus- the 6 P’s
Critical (Chronic) Limb ischaemia
Advanced stage of PAD- triad of ischaemic rest pain, arterial insufficiency ulcers, gangrene. Usually have pink lower limbs due to well developed collateral circulation
Often hang legs out of the bed, and ABPI typically below 0.5
Fontaine classification of PAD
1- asymptomatic PAD
2- pain on exertion (claudication)
3- ischaemic pain at rest
4- necrosis, gangrene, ulcers
Acute limb ischaemia Sx
Pain Pallor Pulse less ness Paralysis Paraesthesia Perishingly old
Differentials of PAD
Spinal stenosis, arthritis, symptomatic Bakers cyst, nerve root compression
Red flags for PAD
Ischaemic rest pain
Ulcers
Gangrene
NB- ask about 6 P’s?
TRALI Transfusion Associated Lung Injury
Sudden dyspnoea, hypoxia, hypotension, fever
Supportive treatment, IV fluids and vasopressors
TRACO Transfusion associated circulatory overload
Dyspnoea
Orthopnoea
Peripheral oedema
Rapid hypertension
Diuretics
AAA Screening
One off USS when 65
Management following AAA Screening
Low rupture risk (asymptomatic, less than 5.5cm)- observe, modify risk factors
High rupture risk (symptomatic, greater than 5.5cm, rapidly enlarging (more than 1cm/year))- refer within 2 weeks to vascular surgery for probable intervention
ABPI
BP legs/ BP arms
1.2+ calcified arteries (esp. diabetics)- refer
1-1.2 normal
0.9-1 acceptable
<0.9 signifies likely disease, less than 0.5 requires urgent referral
Compression bandaging can be used if ABPI is greater than 0.8
3 stages of peripheral arterial disease
Intermittent claudication
Critical limb ischaemia
Acute limb threatening ischaemia
Features of intermittent claudication
Aching or burning in legs following walking
Walk predictable distances before the symptoms start
Relieved within minutes of stopping
Not present at rest
Investigations for intermittent claudication
Cardio vascular examination, observations ABPI Bloods- diabetes, infection etc. Doppler USS MR angiogram of lower limb
6 P’s of acute limb threatening ischaemia
Pale Pulseless Painful Paralysed Paraesthesis Poikilothermia
Acute limb ischaemia due to thrombus
Pre existing claudication with sudden deterioration
No obvious emboli source
Reduced or absent pulses in contra lateral limb
Vasculopaths (widespread vascular disease)
Acute limb ischaemia due to embolus
Sudden onset painful leg
No history of claudication
Obvious source of embolus eg. AF, recent MI
No evidence of PAD (normal pulses in contra lateral limb)
Management of acute limb threatening ischaemia
Initial management- IV heparin (esp.if delay for surgery), codeine, paracetamol, vascular review
Definitive management- Thrombolysis, thrombectomy, bypass surgery, amputation at last resort
Management of PAD
Supportive- address co morbidities eg. Smoking, HTN, DM, obesity, exercise training
Medical- statin (80mg atorvastatin), clopidogrel (preference to aspirin)
Surgical- angioplasty, stenting, bypass, amputation
NB- naftidrofuryl oxalate is a vasodilator used in patients with poor QOL
Criteria for surgery;
- endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
- open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
Superficial thrombophlebitis
Inflammation associated with thrombosis of a superficial vein, typically the long saphenous vein of the leg (usually non infective but it can be infective in nature)
Managed with compression stockings (ABPI first) and NSAIDs
USS to exclude DVT
Management of varicose veins
Conservative- leg elevation, weight loss, regular exercise, graduated compression stockings
Refer to secondary care- pain, discomfort, swelling, bleeding, skin changes secondary to venous insufficiency, superficial thrombophlebitis, active or healed venous leg ulcer
Surgical- ligation, stripping, endothermic ablation, sclerotherapy
Subclavian steal syndrome
Stenotic lesion of the subclavian artery
Decreased cerebral blood flow, syncope
Diabetic foot disease
Secondary to neuropathy (reduced sensation) and PAD (ABPI)
Leriche syndrome
Male patients;
Claudication of the buttocks and thighs
Atrophy of the musculature of the legs
Impotence (due to paralysis of the L1 nerve)
Intermittent claudication vs critical ischaemia
Pain at rest suggests critical ischaemia
Buerger’s disease
(also known as thromboangiitis obliterans)- a small and medium vessel vasculitis that is strongly associated with smoking.
Features; extremity ischaemia intermittent claudication ischaemic ulcers superficial thrombophlebitis Raynaud's phenomenon
Coarctation of the aorta signs on x ray
notching of the inferior border of the ribs
Coarctation of the aorta signs on x ray
notching of the inferior border of the ribs
Neuropathic ulcers
Usually a normal ABPI (caused by neuropathy not PAD)
