Case 18- AAA Flashcards by pio monaghan

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.

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Investigations for DIC

FBC- thrombocytopenia
D dimer- raised
Clotting profile- prolonged APTT, prothrombin and bleeding time
Blood film- schistocytes (microangiographic haemolytic anaemia)

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Older male presents with renal colic

Treat as ruptured AAA

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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

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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.

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Chronic mesenteric ischaemia

Colicky, intermittent abdominal pain. Think of as intestinal angina

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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

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Sx of ischaemic bowel disease

Abdominal pain, melaena, haematochezia, diarrhoea, abdominal tenderness, weight loss, abdominal bruit, signs of shock

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Differentials for ischaemic bowel disease

Infective colitis, ulcerative colitis, large bowel obstruction, acute pancreatitis, gastroenteritis

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Aspirin and the coagulation profile

Only prolongs the bleeding time. All else normal

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Waterhouse Friderichsen syndrome

Adrenal infarcts which lead to adrenal insufficiency during DIC

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Acute limb ischaemia

Sudden lack of blood flow to a limb. Caused by embolism or thrombus- the 6 P’s

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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

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Fontaine classification of PAD

1- asymptomatic PAD
2- pain on exertion (claudication)
3- ischaemic pain at rest
4- necrosis, gangrene, ulcers

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Acute limb ischaemia Sx

Pain 
Pallor
Pulse less ness
Paralysis
Paraesthesia 
Perishingly old

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Differentials of PAD

Spinal stenosis, arthritis, symptomatic Bakers cyst, nerve root compression

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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)