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4Q EM Surg test 2 > CT & CV emergencies > Flashcards

CT & CV emergencies Flashcards

1
Q

Aneurysm def

A

abnormal vessel dilation, (U) defined as 1.5 to 2 times normal size/greater than 50% enlargement

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2
Q

Dissection def

A

a tear in vessel wall in intima & part of media->can create a true & false lumen, compromise branch vessel flow resulting in ischemia & can also rupture through remaining media & adventicia

non-traumatic dissections often occur in underlying aneurysms

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3
Q

Aortic Aneurysmal Disease: definition & causes

A

-degenerative & remodeling of aortic wall
-genetic predisposition & environmental factors
-commonly atherosclerotic
other causes:
A. infection-TB, syphilis
B. Marfan’s, Ehlers-Danos

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4
Q

Atherosclerotic Aneurysms: where, progression, result

A

95% affect abdominal aorta rather than thoracic
-progressive expansion & eventual rupture
-only 14% have symptoms prior to rupture-so HIGH MORTALITY
in ppl who survive initial rupture, 50% or more still die following surgery
almost always have co-morbidities: CAD, PVD, COPD, DM, renal failure

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5
Q

Abdominal Aortic Aneurysm-AAA Dx

A

UTZ (ultrasound) both for dx & to follow size, remember to do UTZ if abdominal complaint or greater than 2-3cm on exam

CT/MRI-use to plan endovascular therapy

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6
Q

Abdominal Aortic Aneurysm (AAA) management

A

less than 5.5cm, not enlarging rapidly, asymptomatic

-UTZ follow-up every 6-12 months

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7
Q

Abdominal Aortic Aneurysm (AAA) indication for intervention

A

greater than 5.5cm or symptomatic

-rapid expansion->0.5cm in 6-12 months

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8
Q

Ruptured Abdominal Aortic Aneurysm symptoms

A

the constellation:
A. Flank/Back Pain
B. HD instability
C. Pulsatile Abdominal Mass

abdominal pain, pulsatile abdominal mass, tenderness & hypotension

EMERGENCY!!!

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9
Q

Management of ruptured AAA

A

ABC, **2 LARGE BORE IVs, type & cross 10 units PRBCs, pain control, UTZ in ED, BP goal 80-100mmHg, EKG-likely have a cardiac history or risks,
Central Line or Swan at some point
**ER or OR
consider endovascular repair if HD stable, contained rupture or impending rupture if available & anatomy acceptable

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10
Q

Surgical repair of AAA

A
  • surgical repair w/Dacron graft
  • percutaneous endovascular stent grafts being used now [endovascular now preferred in many]

-balance operative risk w/risk of rupture
-criteria to repair is:
>or= 5.5cm
>6cm for higher risk patients

Operative mortality:
19% for urgent repairs
50% for ruptures

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11
Q

Debakey classifications of thoracic aortic dissections

A

type I: complete aorta
type II: just ascending aorta
type III: just the descending aorta

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12
Q

Dissections are due to a tear wear, & then what happens

a/w what feeling?

A

due to tear in intima

  • blood penetrates into the media which splits longitudinally
  • can involve thoracic &/or abdominal aorta
  • can occur 2* to connective tissue dz or in presence of aneurysm. Thoracic dissctions are also a/w HTN & trauma

a/w acute onset of “tearing” pain in either chest or abdomen

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13
Q

What is the main way you dx dissections

A

CT scan

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14
Q

Acute aortic dissection (U) starts where?

mortality?

A

in the thoracic aorta
an ACUTE EMERGENCY
mortality 15-20% initially
1% per hour for first 48 hours

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15
Q

risk factors for aortic dissection (3)

A

age
HTN
connective tissue dz (eg Marfan’s)
pregnancy

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16
Q

Where does blood go in an intimal tear?

A

blood penetrates into & splits the medial layer, inner 2/3 & outer 1/3 of media

false channel created-intimomedial flap separates true & false lumens-reentry occurs

17
Q

Aortic Dissection: Potential signs & symptoms

A

-chest pain
-back pain, particularly between shoulder blades
neurologic changes-transient or permanent
-distal ischemia-limbs, gut, kidney
-acute cardiac failure: aortic regurgitation, coronary ischemia
-hypotension & shock: rupture
-hypertension
-discrepant blood pressures (check BPs in all 4 extremities)
-widen mediastinum
-pleural capping
-pleural effusion
-hoarse voice

18
Q

TRIAD OF AORTIC DISSECTION-constellation

A
  1. Abrupt onset of thoracic or abdominal PAIN with a sharp, tearing quality
  2. Mediastinal and/or aortic WIDENING on chest radiograph
  3. HTN +/- DISCREPANT BP or pulse (absence of a proximal extremity)
19
Q

Aortic Dissection: subsequent management -TYPE A

A 
75% of cases
emergent surgery in all patients
mortality>50% within 48 hours
complications:
1. aortic rupture
2. cardiac tamponade
3. acute aortic regurgitation
4. acute coronary ischemia
20
Q

Aortic Dissection: subsequent management- TYPE B un complicated

A

type B uncomplicated (no rupture or ischemia)=medial therapy

21
Q

What is Type B complicated & what is the tx

A

Type B complicated or failed medical management in characterized by

  1. persistent pain
  2. progression of dissection
  3. Marfan’s

tx: surgical or endovascular tx
- endovascular therapy can be effective when tailored to specific indication such as contained rupture & in some cases of branch vessel ischemia

22
Q

Aortic Dissection imaging

A

Spiral CT Scan: gold standard
MRI (good for following, but not dz/tx)
TEE: may miss distal tears, good for evaluation of aortic valve proximal root

23
Q

Initial medical management of aortic dissection

A
  1. reduce systolic BP
  2. decrease LV dP/dT (force of ejection of the heart)
  3. pain control
    Beta blockers first, then add vasodilators like Nipride
24
Q

Thoracic Aortic Aneurysm-Invasive tx

A

Ascending and/or arch: sternotomy surgical repair +/-aortic valve

Descending Aorta: left Thoractomy

  • surgical repair OR
  • endovascular repair/graft
25
Q

What is the most common cause of aortic dissection in a woman under 40?

A

PREGNANCY

26
Q

Transection of thoracic aorta causes, clinical clue

A

accounts for 1.5-2% of blunt thoracic trauma
RAPID DECELERATION-(MVA/falls)
-accounts for 15% of deaths following MVA

pt responds to fluid, then hypotension, responds to fluid, then hypotension: stop & go to OR, avoid HTN rupture

27
Q

Thoracic Aortic Injury: Transection dx (7)

A
  • ‘funny-looking mediastium’
  • blurred aortic knob
  • widened mediastinum
  • 2nd rib fracture
  • pleural effusion
  • apical capping
  • CXR then spiral CT scan, angiogram if equivocal
28
Q

Thoracic Aortic Injury: Transection Management

A

open repair vs. endovascular repair if available

  • clamp & run, vs. partial bypass
  • high risk of paraplegia (artery of Adamkiweicz

-if aorta is injured but not the source of active hemorrhage, if should be lower on list of management after hemorrhage control (abdomen/pelvin) & neuro stabilization

4Q EM Surg test 2 (4 decks)

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