Emergencies Flashcards
How do aneurysms occur?
Progressive, permenant dilatation
>50% of its original diameter
True aneurysm= all layers of arterial wall
What are the different types of aneurysms?
Fusiform: AAA
Sac like: Berry aneurysm
Where are common sites for aneurysms?
Aorta
Iliac
Femoral
Popliteal
What size constitutes a AAA?
Abdominal aorta >3cm
What are risk factors for an aneurysm?
Heart disease HTN >50yo Male Smoking hyperlipidaemia
How do AAA present?
Asymptomatic
Abdo pain radiates to back/groin/iliac fossa
Expansile, pulsatile abdo mass
RUPTURE: Acutely unwell, Drowsy, confused, ↓GCS, syncope, shock, ↓BP and absent leg pulse
How is a AAA investigated?
Urgent USS: <5.5cm + unruptured = USS screening
Bloods: FBC, Clotting, U&E, LFTs, G&S/CM, ESR
AXR: Loss of psoas shadow & dilated abdominal aorta
How is a AAA managed?
Watch & wait
USS Screening: 3-4.4cm = annually, 4.5-5.4cm = 3monthly
>5.5cm/Sx/>1cm growth per year = elective surgery (EVAR)
Rupture = immediate repair
How does an aortic dissection occur?
Intramural bleeding → disruption of medial layer of aortic wall creating a false lumen and true lumen
Where are aortic dissections usually found?
Ascending aorta
Aortic arch
What are the risk factors for aortic dissection?
Male 50-70 HTN Smoker Cardiac surgery Drug abuse Trauma CT: Marfan's, Ehler's Danlos Genetic: Turners, Noonan's
How does an aortic dissection present?
Sudden onset tearing chest pain radiating to back
Unequal radial pulses (indicates forward tear)
Dyspnoea/syncope
Murmur-Aortic regurg
Pleural effusion
How is aortic dissection classified?
Stanford=
Type A: ↑aorta +/- arch & ↓aorta - 70%
Type B: No ↑aorta. Involves the ↓thoracic (distal to L subclavian artery) and/or abdominal aorta.
OR
DeBakey=
Type 1: Originates in ↑aorta, involves the aortic arch +/-↓thoracic aorta.
Type 2: Just ↑aorta
Type 3: Distal to L subclavian artery, extends through the thoracic aorta (3A) or extends beyond the visceral segment (3B).
How is an aortic dissection investigated?
CT ANGIO = DIAGNOSTIC
CXR
ECG: LV ischaemia
ECHO (TOE): Aortic root leak/effusion/regurg
What can be seen on a CXR of someone with an aortic dissection?
Widened mediastinum
Double knuckle aorta
Tracheal deviation (away)
Pleural effusion (L>R)
How is aortic dissection treated?
IV access + analgesia
Crossmatch 10u of blood
Maintain sBP 100-120 w/Labetalol or Esmolol
Surgery (usually Type A): Stent or graft
What are the complications of an aortic dissection?
Paraplegia: Anterior spinal artery loses blood supply from aorta
Pericardial tamponade
MI: Backwards tear = Inf MI
Renal/mesenteric/limb ischaemia
What are the causes of a tamponade?
Pericarditis Dissection Haemodialysis Warfarin Trans-septal puncture Trauma- bleed into pericardial space
What is Beck’s triad?
Seen in tamponade ↑JVP, muffled heart sounds + hypotension (despite fluid resus) Other signs: Pulsus parodoxus Kussmaul sign (related to JVP)
How is tamponade treated?
Pericardiocentesis
What is SVCO?
Tumour encroaches & obstructs SVC
What are the causes of SVCO?
Malignancy >90% Goitre Mediastinal fibrosis Infection (TB) AA Idiopathic
What cancers can cause SVCO?
Lung 75% Mediastinal lymphoma Oesophageal Ca Germ cell tumours Thymoma (?Myasthenia)
How does SVCO present?
Dyspnoea + Cough ± Stridor Headache worse on coughing Facial oedema Distended neck & chest veins + ↑JVP Cyanosis (facial) Hoarse voice Visual disturbance Pemberton's test +ve
How is SVCO investigated?
URGENT CXR- look for mass
Contrast CT thorax
What signs will be seen on a +ve Pemberton’s test?
Facial cyanosis/ plethora
↑JVP
Stridor
How is SVCO managed?
Dex 16mg w/PPI
Balloon venoplasty + SVC STENT
Tx cause- Chemo/RT
What is the prognosis with SVCO?
Depends on cause
GOOD = SCC
POOR = Mesothelioma
Where is acute mesenteric ischaemia most commonly found?
Small bowel following superior mesenteric artery/vein thrombus
What are the risk factors for acute mesenteric ischaemia?
↑age AF Emboli RF's CV RF's Cocaine use
How does acute mesenteric ischaemia present?
Acute severe tender abdo (central + constant) Soft abdomen w/no signs Rapid hypoV (SHOCK) Fever
How is acute mesenteric ischaemia investigated?
MESENTERIC ANGIO or CT/MRI = DIAGNOSTIC (also for chronic mesenteric ischaemia)
Bloods: ↑Hb (plasma loss), ↑WCC
ABG: Persistent metabolic lactic acidosis
AXR: Gasless abdomen
How is acute mesenteric ischaemia managed?
IV Fluid resus- ASAP!
Abx: Met + Gent
LMWH
Surgery: Urgent to remove necrotic bowel
What are the complications of acute mesenteric ischaemia?
Septic peritonitis: Rebound tenderness + guarding
How does chronic mesenteric ischaemia present?
AKA intestinal angina
Post-prandial colicky pain
Weight loss
Upper GI bruits +/- PR bleed +/- malabsorption
How is chronic mesenteric ischaemia managed?
Surgery
Percutaneous transluminal angioplasty
How does ischaemic colitis present?
Post-prandial abdo pain
N&V
AXR shows thumb-printing
Hx of CVD/MI/AF/HTN
How does a patient with AF typically present when considering acute mesenteric ischaemia?
AF w/acute tender painful abdo Soft on exam Lactic acidosis HypoV Hx of CVD Degree of illness out of proportion to exam findings
