ORALS - VASCULAR Flashcards

1
Q

AORTIC DISSECTION CASE

A

CLINICAL CASE - BP difference in both arms, radial pulse discrepancy, muffled heart sounds, cool limb + HTN, CP, neuro symptoms

  1. MOVID
    IV, art line
    b/L Blood pressures
    BW - trop/CK
    EKG - inferior STEMI, alternans, CXR
    EXAM - US (effusion, aortic root dilusion, AR, dissection flap)
  2. MGMT
    Analgesia - fentanyl (will also help decr sympathetic drive)
    HR control (60) - labetalol 20mg Q5-10min, esmolol 500mcg => 100mcg-300mcg/kg/min
    SBP control (120) - nitroprusside 0.5-3mcg/kg/min (reflex tachy, use after BP control)
    fentanyl for pain
    other meds - nicardipine, nitroglycerin
    PRBC +/- Blood
    CTA
  3. Consults
    CV vs vascular surgery consult
    ICU

follow up questions
1. XR findings of AD
Mediastinal widening
abnormal aortic contour
calcium sign
apical pleural CAP
loss of PA window
oblinteration of aortic knob
displacement of trachea
displacement of NG
depression of L mainstem
pleural effusion

  1. Describe the 2 different classifications of AD
    STANFORD: A (Ascneding) / B (not involved in ascending)
    DEBAKY: 1 (ascending + distal) / 2 (ascending/arch) / 3 (descending)
  2. Risk factors for AD
    HTN
    Male
    Advanced age
    Hx of cardiac surgery
    Bicuspid valve
    Marfans
    Stimulant use
  3. Complications of AD
    AR
    tamponade
    CHF / MI (RCA)
    dissection into coronary
    spinal cord ischemia
    horners
    ischemic bowel / mesenteric ischemia
    ischemic limb
    GIB
    CV
  4. what is the cause for low / normal BP in AD
    => dissectioninto pericardium = tamponade
    => dissection into subclavian (pseduoaneurysm)
    => dissection of renal arteries
    => free wall rupture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

AAA CASE

A

CLINICAL case: back pain, syncope, thromboembolic event, compression of adjacent structure, pulsatile mass, GIB, bruit

1)MOVID
BW - trop, CK
ECG/CXR
US - AAA >3cm, free fluid

2) MGMT
analgesia
PRBC +/- MTP
art line (SBP goal 80-100 for cerebral perfusion)
CTA

3) Consults
vascular surgery

follow up questions
1. ddx for AAA
Renal Colic
Pancreatitis
Intestinal ischemia
Chole
Appy
Perf
MI
MSK back pain
Bowel obstruction

  1. List spaces into which AAA can bleed into
    retroperitoneum
    intraperitoneal
    GIB
    IVC - high output failure
  2. Hypotension post DC from hospital for AAA repair
    consider complications
    graft infection - ABX, image
    AEF/GIB - give blood, image
    anastomotic leak - give blood, image
    endoleak - blood, image
    consult vascular surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

ISCHEMIC LIMB CASE

A
  1. MOVID
    BW - INR/coag panel
    exam - determine if limb theratening (paralysis, P’s)
  2. MGMT
    analgesia
    ASA
    Heparin 80U/kg bolus => 18U/kg/hr
    If thrombotic: thrombectomy, bypass graft, amputation
    If embolic: fogarty catheter embolectomy
  3. Consults
    vascular consult

follow up questions

  1. List contraindications to heparin
    hx of HIT
    Neurosurgery (in last 2wks)
    major surgery in last 48H
    child birth in last 24H
    bleeding diathesis
    thrombocytopenia
    active bleeding
  2. DDX for limb ischemia
    arterial occlusion (thrombotic / embolic)
    phlegmasia cerulea or alba dolens
    dissection
    spinal SAH
  3. Difference btwn thrombotic + embolic phenomena
    Thrombotic - chronic, progressive
    => hx of claudication symptoms
    => C/L limb with decr pulses
    => PAD exam (scaly skin, no hair, arterial ulcers)

Embolic -
=> hx of afib
=> sharp demarcation
=> sudden
=> no other signs of pAD
=> hx of AF, recent MI, AAA, MS

  1. How to trouble shoot poorly functioning indwelling line
    XR to confirm placement
    assess for DVT
    see if change in body position helps
    consider TPA (5000U, clamp x30min)
  2. Describe the difference btwn phelgmasia cerulea + alba dolens
    phelgmasia alba dolens - arterial insufficiency 2’ spasm (no ischemia)
    Phelgmasia cerulea => ileofemoral DVT
    - pain, venous gagrene
    - compartment syndrome

mgmt = heparin, vascular consult (thrombolysis, thrombectomy, IR)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

HTN CASE

A

CASE : BP 200/120 and EOD

  1. MOVID
    BW - trop/CK
    EKG,CXR
    urine tox
    US - b lines, volume overload, LVH, possible dissection
  2. MGMT
    treat pain (analgesia)
    treat agitation
    CT brain
    antihypertensives
    => labetalol 20mg IV (doulbe until dose that works) Q15
    => esmolol 500mcgIV => 50-200mcg/kg/hr
    => nitroprusside
    => nitro 0-800mcg/min
    => hydralazine 10-20mg IV

FOLLOW UP QUESTIONS

  1. What are GOALS for HTN emergency in the ED:
    decr MAP 10-20% in first 1-2H for HTN encephalopathy / PRES (not >25% in first day)
    HTN ICH => goal less than SBP 160 in first hr
    SAH: SBP160 / MAP 110
    Ischemic stroke: 185/110 (TPA), 220/120 (no TPA) and decr by 15% in first 24H
  2. List for signs of treatable causes of HTN
    Pre eclampsia
    Pheo
    Dissection
    Stroke
    ICH
    Cushings
    Thyrotoxicosis
    Sympathomimetics
    ETOH w/d
  3. What is concerning for hypertensive emergency
    MAP >130-135 with EOD (ie HTN encephalopathy, AKI, +trop with symptoms / ECG changes, pulm edema)
  4. Causes of HTN
    non adherence with antihypertensive meds
    non adherence w CPAP / BIPAP
    volume overload
    pain, anxiety, urinary obstruction
    sympathomimetic drugs
    withdrawal (ETOH, benzo)
    stroke (ischemic stroke, ICH, SAH)
    Acute pulmonary edema
    aortic dissection
    pre-eclampsia
    endo - pheo, cushings, hyperthyroidism
    renal - scleroderma renal crisis, renal artery stenosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

DVT CASE

A
  1. List ddx for DVT
    Bakers cyst
    cellulitis
    vasculitis
    fracture
    venous insufficiecny
    superficial thrombophlebitis
  2. Describe WELLS crtieria for DVT (C3P2OTR2D2)
    Cancer
    Calf swelling >3cm
    Collateral veins present
    Pitting edema
    Prev DVT documented
    Oedema of entire leg
    Tenderness to calf
    Recent paralysis / plaster / paresis of lower extremity
    Recent surgery 12wks or immobilization 3days
    Diff dx more likely (-2)
    0-2 (D dimer) / >3 (D dimer + US)
    RPT US in 1wk if neg US +Ddimer
  3. Management for DVT
    apix 10mg BID X7 D => 5mg BID
    rivaroxaban 15mg BID X21D => 20mg daily
    preg LMWH
  4. Approach to distal + superficial venous thrombosis
    DISTAL: AC IF:
    - 5cm in length
    - within 3cm from popliteal
    - hx of DVT, cancer, ++increased DD, multiple, preg, inpatient

SF:
- rpt US in 7d (if high risk)
- AC if >5cm x45d
- within 3cm, but less 5cm = NSAID
- >5cm from saphenopopliteal junction but >3cm = treat if plus symptoms / risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

PE CASE

A
  1. Wells criteria for PE (LASTPCH)
    Leg swelling +3
    Alternative dx unlikely +3
    Surgery (4wks) / Immobilization (3d) 1.5+
    Tachycardia >100 +1.5
    Prev DVT / PE +1.5
    Cancer (6mos) +1
    Hemoptysis +1
    >5 - CTPE / 0-4 - dimer alone
  2. PERC criteria (HADCLOTS)
    H - hormones
    A - age >50
    D - DVT / PE hx
    C - coughing up blood
    L - leg swelling
    O - O2 95%
    T - tachy >100
    S - surgery in 4wks
  3. Describe CXR findings of PE
    Westermark sign= oligemia due to collapsed vessels
    Hampton’s hump= wedge opacity of infarct
    Atelectasis
    Effusion
    Fleschners sign- enlarged PA
  4. ECHO findings of PE
    TAPSE less than 2cm
    RV hypokinesis
    RV dilation > ⅔ size of LV
    McConnell’s sign (hypokinesis mid free wall but normal apex
    Dilated IVC
    D sign/septal flattening
  5. EKG findings of PE
    Sinus tachy
    S1Q3T3
    Tall R wave in V1
    TWI in V1-4 moost specific
    RAD
    RBBB
    STE in AVR
  6. Define SUBMASSIVE PE + TX
    acute PE + hypotension PLUS
    RV dysfunction OR
    elevated trop
    MGMT:
    => heparin
    => consider lytics with severe rV dysfxn, trop, worsening resp status, unstable (per AHA, not thrombosis cda)
  7. Define MASSIVE PE + TX
    acute PE PLUS
    => sustained hypotension (less than 90) x15min
    => requiring vasopressor support
    => persistent brady 40
    => MI
    MGMT
    => arrest 50mg q15min
    => pulse 100mg /2H
    => cath thrombolysis, embolectomy
  8. Describe the YEARS score
    YEARS criteria
    • Clinical signs of DVT
    • Hemoptysis
    • PE most likely
      => 0 = ddimer (1000 CUT off)
      => >1 = ddimer (500 CUT off)
      => pregnancy => ultrasound, d dimer (500 cut off)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

VASCULAR INJURY

active hemorrhagic inury

A
  1. PPE/MOVID
    type and screen +/- MTP
  2. MGMT
    direct digital pressure
    avoid blind clamping
    apply tourniquet => let down q30min + monitor close
    if unable to get control => insert foley and use balloon to tamponade

FOLLOW UP QUESTIONS

  1. Describe hard + soft signs of peripheral vascular injury (HAAA)
    Hematoma
    Abscent distal pulse
    Arterial hemorrhage (pulsatile)
    Audible bruit (palpable thrill)
    SOFT
    non expanding hematoma
    decr distal pulses (decr ABI)
    ++hemorrhage
    peripheral nerve injury
    bone/penetrating prox wound
  2. ABI SBP leg / arm
    API SBP injured / uninjured
  3. Describe warm and cold ischemic time
    warm ischemic time = 6H (10% - irreversible damage)
    cold ischemic time = 12-24H (ischemia without reversible damage is extended)
  4. Describe 3 complications of pseudoaneurysm
    rupture
    compression of adjacent tissues
    embolization
  5. High risk mechanisms for vascular injury
    bite
    crush
    major joint dislocation
    shot gun wound
    wounds within 1cm to NV bundle
  6. NV bundle associated with artery
    axillary = brachial plexus
    brachial = median
    radial = median + radial
    ulnar = ulnar
    femoral = femoral
    popliteal = tibial nerve
How well did you know this?
1
Not at all
2
3
4
5
Perfectly