ORALS - VASCULAR

Question 1

AORTIC DISSECTION CASE

Answer 1

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

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

Question 2

AAA CASE

Answer 2

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

2. List spaces into which AAA can bleed into
   retroperitoneum
   intraperitoneal
   GIB
   IVC - high output failure
3. 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

Question 3

ISCHEMIC LIMB CASE

Answer 3

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

4. 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)
5. 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)

Question 4

HTN CASE

Answer 4

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

Question 5

DVT CASE

Answer 5

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

Question 6

PE CASE

Answer 6

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)

Question 7

VASCULAR INJURY

active hemorrhagic inury

Answer 7

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