KC Vascular Flashcards
*Indication-Specific Approach to Management of Hypertensive Emergencies
1. ACS
2. Heart failure
3. Aortic Dissection
4. Acute ischemic stroke or intracerebral hemorrhage
5. Hypertensive encephalopathy
6. AKI
7. Pre-eclampsia
8. Sympathetic crisis
- Nitroglycerin
- Nitroglycerin
- Esmolol (and fentanyl)
- Nicardipine
- Nicardipine
- Nicardipine
- Nicardipine/Hydralazine or labetalol depending on source
- Phentolamine
List 10 secondary causes of hypertension
Endocrine: Cushing’s, hyperaldosteronism, OCP, pheochromocytoma, thyroid disease
Pulmonary: OSA
Renal: Pyelonephritis, diabetic nephropathy, nephritic and nephrotic syndrome, Polycystic kidney disease, renovascular conditions (renal artery stenosis)
Vascular: atherosclerosis, coarctation of the aorta
Toxic: alcohol use, sympathomimetic, tyramine containing foods
List 10 signs of end organ failure in hypertensive emergency
CNS: stroke, encephalopathy, spontaneous hemorrhage, headache, altered mental status, seizures, PRES
Retinal: retinopathy, vision changes, exudates, papilledema, splinter hemorrhages, cotton-wool spots
Renal: AKI, nocturia, proteinuria, hematuria
Cardio: ACS, CHF, LVH
Vascular: dissection
GI: N/V, abdo pain, elevated liver enzymes
Other: eclampsia
List general management principles for HTNive emergency in the ED
Target BP management based on SX
BP should never be rapidly lowered (except in aortic dissection)
MAP should be gradually reduced by 25% in the first 24 hours (10-20% in the 1st hour)
List BP targets and preferred agents in the following:
Hypertensive encephalopathy
Preeclampsia
Pheochromocytoma
Aortic dissection
ACS
Tox sympathetic crisis
Hypertensive SAH
Hemorrhagic stroke/spontaneous ICH
Ischemic stroke
Hypertensive encephalopathy: R/O stroke with CT first. Then lower by 20-25%, target 160/110. Preferred agents labetalol, nicardipine, enalapril. Avoid hydralazine and nitro
Pre-eclampsia: Lower to <140/110 via magnesium, labetalol, hydralazine
Pheochromocytoma: Phentolamine. Avoid beta blockers
Aortic dissection: SBP 100-140 and HR <60. Pain control, esmolol
ACS: Titrate to symptom relief, lower SBP <180. Nitroglycerin
Tox sympathetic crisis: benzos, phentolamine
SAH: SBP<140-160 to prevent rebleeding, avoid hypotension (iNTERACT trial). Labetalol first line
Hemorrhagic stroke/spontaneous ICH: SBP <140-180, higher pressure will drive the bleeding
ICH: MAP 110, maintain CPP >60 and SBP <140
Ischemic stroke: SBP <180 is TPA candidate, otherwise <220. Labetalol and nicardipine
List 7 meds and their doses that can be used in HTNive emergencies
Labetalol 10-20 mg IV bolus, 0.5-10 mg/min infusion
Esmolol 0.5-1 mg/kg IV bolus, 50-500 mcg/kg/hr
Metoprolol 1.25-5 mg IV bolus, with repeated doses as needed
Diltiazem 0.25-0.35mg/kg IV bolus then 5-15 mg/hr infusion
Nicardipine 5-15 mg/hr infusion
Nitroglycerin 0.4mg SL, 10-20 mcg/min infusion
Nitroprusside 0.5mcg/kg/min IV
Hydralazine 10-20 mg bolus
Enalapril 0.625-1.25mg IV
4 RF for dissection
Risk factors as per the CAEP CPG 2020: connective tissue disorder, aortic valve disease, recent aortic manipulation, family hx of AAS, aortic aneurysms
Other risk factors: HTN, advanced age, pregnancy, male sex, cocaine, coarctation of the aorta
What is the Stanford classification of dissection
Type A dissections involve the ascending aorta and account for approximately 62% of all dissections.
Type B dissections involve only the descending aorta and account for 38% of dissections.
What are blood pressure and heart rate targets for dissection?
BP 100-120 mmHg
HR less than 60 beats/min
What are 3 imaging modalities that have > 95% sensitivity for detecting dissection?
• TEE,
• CT,
• MRI
Some patients may have a blood pressure differential between arms, what is the mechanism behind this?
Pseudohypotension, a condition in which the blood pressure in the arms is low or unobtainable, and the central arterial pressure is normal or high, may be present. This results from the interruption of blood flow to the subclavian arteries.
What are three causes of syncope in a patient with dissection
Dissection into the pericardium, causing pericardial tamponade
Hypovolemia
Excessive vagal tone
Cardiac conduction abnormalities
2 diagnostic methods to confirm aortic dissection and 2 disadvantages of each
TEE: Needs an experienced operator and equipment not always available in the ED
CT: Needs to leave department, radiation
2 drugs to use to maintain BP and HR targets in aortic dissection
Fentanyl and Esmolol
2 other drugs you could use in isolation (for aortic dissection) but may cause rebound tachycardia
- Nitroglycerin
- Sodium nitroprusside
Does a negative D dimer r/o dissection?
No
What is the DeBakey classification for aortic dissection
Type 1: ascending aorta, arch, descending aorta
Type 2: ascending aorta only
Type 3: descending aorta only
remember this is at brachiocelhalic artery
What type of MI may present in a dissection? Why?
Inferior due to RCA dissection
List 5 x ray findings seen in aortic dissection
Pleural effusions (esp left), Widened mediastinum, Abnormal aortic knuckle, ‘Calcium’ sign: calcium separated from aortic wall by 5mm, Double density of aorta, Paraspinal stripe, Tracheal shift to the right, Pleural cap (left apical obliteration of the medial aspect of the L upper lobe)
List 3 ECG findings that may be seen in aortic dissection
Inferior STEMI, LVH, heart block
List 4 high risk pain features in aortic dissection
List 4 high risk physical exam findings in aortic dissection
Can a D-dimer be used in aortic dissection
List 5 complications of aortic dissection
tamponade, MI (RCA), vessel occlusion, neuro injury (stroke, anterior spinal artery), mesenteric ischemia, AKI
*Guy w/ AAA EndoVascular repair 4 months ago presents w/ hematemesis, what is the diagnosis?
Aorto-enteric fistula
*2 imaging modalities for aorto-enteric fistula?
i. CT angiography
ii. Endoscopy
*4 complications specific to open AAA repair
- Graft infection
- Graft migration
- Graft thrombosis
- Pseudoaneurysm
- Aortoenteric fistula
What is the difference between a true and pseudoaneurysm
True aneurysm involves all layers of the vessel wall
List 4 types of endoleak
Type 1: Leak due to incompetent seal at the proximal or distal segments of stent
Type 2: Leak into the graft from branch vessels ex. Inferior mesenteric (often resolve spontaneously)
Type 3: Leak due to failure of anastomosis between stent components
Type 4: Leak through graft material
List 4 features on history suggestive of acute arterial embolus
Sudden onset
No Hx claudication
Afib
PFO
Hx of same
Known LV thrombus
List 4 features on exam suggestive of acute arterial embolus
- Pain
- Pallor (sharp demarkation)
- Pulselessness
- Paresthesias
- Paralysis
- Poikilothermia (cold)
2 immediate management steps
- ASA
- Heparin
What is the definitive treatment for this patient?
Fogarty catheter embolectomy
List 6 vascular pathologies that may cause ischemia
Atherosclerosis, aneurysms, embolism, thrombosis, inflammation, trauma, vasospastic disorders, AV fistulas
How is peripheral vascular disease defined?
ABI <0.9
What are the 6 Ps of limb ischemia
Pain, pallor, paralysis, pulselessness, paresthesias, polar
Differentiate between thrombosis and embolism as a cause for distal ischemia
Thrombosis: intermittent claudication, gradual onset. Less likely to show occlusive disease due to collaterals
Embolism: sudden onset of ischemic symptoms
List 2 medical and 2 surgical treatments for vascular ischemia
Medical: Unfractionated heparin, fibrinolytic therapy
Surgical: catheter directed thrombolysis, thrombectomy, bypass graft, angioplasty with stents
What is the cause of blue toe syndrome
Atheroembolism: micro embolic made of cholesterol and calcium that break off from proximal atherosclerosis and lodge in distal arteries
List 5 ways aneurysms can become symptomatic
1) rupture with hemorrhage 2) impingement on adjacent structures 3) occlusion of a vessel 4) embolism from a mural thrombus 5) pulsatile mass
What is Buerger’s disease
Inflammation and clotting in small and medium sized arteries and veins of distal extremities
Dx: 1) history of smoking 2) onset before age of 50 3) infrapopliteal arterial occlusive lesions 4) upper limb involvement 5) absence of other atherosclerotic risk factors
What is a mycotic aneurysm and a common site
Infected aneurysm due to endocarditis; septic emboli implant in non aneurysm arteries that become damaged, or in the vasa vasorum of larger vessels
Aortic and SMA
List 3 vasospastic disorders
Raynaud’s, livedo reticularis, acrocyanosis
List 3 types of thoracic outlet syndrome
Neurogenic, venous, artery
Differentiate between arterial, venous, and diabetic ulcers
Arterial: well demarcated, punched out, minimal exudate, improves with leg down.
Venous: exudative with granulation tissue, improves with leg up
Diabetic/neuropathic: dry, cracked, insensate. No pain. On pressure points
*What scoring system can help with admission vs outpatient management of PE
Modified Hestia Criteria to Select Patients With Deep Vein Thrombosis and/or Pulmonary Embolism for Outpatient Treatment. Low risk if:
• Systolic blood pressure > 100 mm Hg
• No thrombolysis needed
• No active bleeding
• Oxygen required to maintain oxygen saturation > 94%
• Not already anticoagulated
• Absence of severe pain requiring > two doses of intravenous narcotics
• Other medical or social reasons to admit
• Creatinine clearance > 30mL/min
• Not pregnant, severe liver disease, or heparin-induced thrombocytopenia
*5 findings consistent with PE on ECG (which is most specific)
Sinus tachycardia
RBBB
T-wave inversions in the right precordial leads (V1-4) as well inferior II, III, avf (If have all of these, verrrry specific for PE)
SI QIII TIII pattern
Right axis dev
Big R-wave v1 (acute right ventricular dilatation)
peaked P wave in lead II > 2.5 mm in height (Right atrial enlargement)
atrial tachycardias
non-specific ST changes
*What are the criteria in the PERC rule
HAD CLOTS
Hormones
Age (>= 50)
DVT/PE (Hx)
Coughing Blood
Leg Swelling
O2 Low
Tachycardia
Surgery/Trauma
*2 specific interventions for submassive or massive PE
- Heparin
- Fibrinolytic
- Catheter-directed fibrinolysis
*4 ultrasound findings of PE
RV wall hypokinesis
- Moderate or severe
- McConnell’s sign
RV dilatation
- End-diastolic diameter >30 mm in parastemal view
- RV larger than LV in sobcostal or apical view
- Increased tricuspid velocity >26 m/sec
- Paradoxical RV septal systolic motion
Pulmonary artery hypertension
- Pulmonary artery systolic pressure >30 mmHg
- Dilated IVC with lack of respiratory collapse
*7 components of Wells criteria for PE
*3 components of PERC that are not part of Wells
- Age >= 50
- SaO2 on room air < 95%
- Hormone use
*What are 4 reasons for false negative d-dimer for PE?
very small isolated subsegmental PE
chronic PE
severe lipemia
ongoing warfarin therapy
*5 lab or imaging findings of RV dysfunction in PE (not physical or ECG findings)
- Elevated troponin
- Elevated BNP
- POCUS: see above
*7 non-DVT causes of this presentation, leg swelling unilateral
- Chronic venous insufficiency
- Cellulitis
- Muscle strain/tear
- Baker’s cyst
- Hematoma
- Claudication/ischemia
- Intra-abdominal compression
- Unrecognized trauma
- Compartment syndrome
- Myositis
*What is d-dimer?
Breakdown product of cross-linked fibrin
*What are 5 other causes of elevated D-dimer?
Lung Ca
MI
Aortic dissection
recent surgery
Pregnancy
*Outline the Wells DVT score
C3P2O R2D2
1 Cancer Rx <6m / palliative
1 Calf swelling >3cm
1 Collateral superficial veins
1 Previous DVT
1 Pitting edema (unilateral)
1 Obviously swollen leg
1 Recently bedridden >3d / surgery <12w
1 Recent paralysis / plaster immobilization
1 Deep venous system is tender
-2 Diagnosis (alt) at least as likely a DVT
0 Low (5%)
1-2 Mod (17%)
> 3 High (17-53%)
*His leg becomes swollen and blue what is it called (DVT)
Phlegmasia Cerulea Dolens
*3 indications for thrombolytics in PE
- SBP < 90 mmHg for > 15 mins (or drop by 40 from baseline)
- Episodic hypotension (SBP < 90 mmHg)
- HR/SBP (shock index) consistently > 1.0
- Respiratory failure (SpO2 < 92% with distress)
- Suspected PE and cardiac arrest
- Large clot burden
- RV strain with any BP drop
Dose: Alteplase 100 mg IV over 2 h (50mg bolus, then 50mg over 1h)
*What is the post-test if all PERC criteria negative?
< 2%
*4 CXR findings of PE
Hampton’s Hump
Westermark’s
Pleural effusion
Atelectasis
(?Normal)
List the deep veins of the legs
calf veins (ant/post tibial, peroneal) —> popliteal —> (superficial) femoral —> joined by deep femoral and greater saphenous to form common femoral —> external iliac
What types of SVT should be treated
<3cm from saphenofemoral junction
Explain risk stratification using the Wells score
Wells <4.5 PE unlikely; these patients can have a d-dimer (and age adjusted d-dimer) and if negative PE is ruled out Wells >4/5 PE is likely; these patients should proceed directly to imaging
Explain the YEARS score
Van der Hulle T et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017; 390:289-297.
Bottom line: Can use a d-dimer threshold of 1000 if all three YEARS are negative: clinical signs of DVT, hemoptysis, PE most likely diagnosis
Population: 3465 inpatients and outpatients with suspected PE
Intervention: YEARs criteria
Control: Standard practice (Wells)
Outcome: #VTE in 3 mo follow up: 0.61%. Reduced number of CTPA by 14%
He has clinical signs of DVT, PE is most likely - if all three negative, use threshold of 1000
Explain age adjusted D-dimer
Age adjusted: dimer should be less than age*10
Population: multicentre prospective management trial (not RCT) in 19 centres in Europe
Intervention: Patient with age adjusted D dimer did NOT undergo CTPA
Control: No control arm
Outcome: 1 nonfatal PE 0.3%, 11.6% absolute increase or 41.2% relative increase in ‘negative’ d-dimers
List 2 medications that can be started for management of outpatient low risk PE that do not require bridging
Rivaroxaban
Apixaban
LMWH is required for dabigtran and edoxaban
List 2 medications that can be started in hospital for high risk PE
Unfractionated heparin 80u/kg bolus then 18u/kg/hr. Longer time to therapeutic window. Used if reversibility needed, or in patients with renal failure
LMWH: dalteparin 200IU/kg SC OD, enoxaparin 1mg/kg SC. Cannot be used in renal failure
When should thrombolysis be considered?
Hemodynamically unstable PE
What is the dose of thrombolysis
Alteplase 100 mg over 2 hours
List 2 ultrasound findings of PE
Dilated RV, McConnell’s sign (apical contraction discordant to free wall contraction)
List 5 causes of elevated D-dimer other than vte
Pregnancy, sepsis, DIC, postoperative, malignancy
6 reasons to take type B or OR dissection
iscehmic limb
mescenteric ischemia
Renal ischemia
Rupture
Refratory pain
Progressive dissection
VTE Bled score
cancer, hx bleeding, therefore anemia, male with HTN, therefore renal dysfunction
For clinically relevent bleeding after day 30 on anti coagulation
DVT medication dosing PO
Apixiabn 1 week 10mg then 5mg PO BID
Reasons to treat distal DVT
2020 review from JAMA[8] recommend treat calf DVT if “severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer).”
What are locations for 2 and 3 point DVT POCUS?
2 point - common femoral to bifurcation with deep femoral
And popliteal to trifurcation (ant, post, peroneal)
3 point - add in superficial femoral where it comes off common
