ORALS - VASCULAR Flashcards
AORTIC DISSECTION CASE
CLINICAL CASE - BP difference in both arms, radial pulse discrepancy, muffled heart sounds, cool limb + HTN, CP, neuro symptoms
- 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) - 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 - 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
- Describe the 2 different classifications of AD
STANFORD: A (Ascneding) / B (not involved in ascending)
DEBAKY: 1 (ascending + distal) / 2 (ascending/arch) / 3 (descending) - Risk factors for AD
HTN
Male
Advanced age
Hx of cardiac surgery
Bicuspid valve
Marfans
Stimulant use - Complications of AD
AR
tamponade
CHF / MI (RCA)
dissection into coronary
spinal cord ischemia
horners
ischemic bowel / mesenteric ischemia
ischemic limb
GIB
CV - what is the cause for low / normal BP in AD
=> dissectioninto pericardium = tamponade
=> dissection into subclavian (pseduoaneurysm)
=> dissection of renal arteries
=> free wall rupture
AAA CASE
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
- List spaces into which AAA can bleed into
retroperitoneum
intraperitoneal
GIB
IVC - high output failure - 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
ISCHEMIC LIMB CASE
- MOVID
BW - INR/coag panel
exam - determine if limb theratening (paralysis, P’s) - MGMT
analgesia
ASA
Heparin 80U/kg bolus => 18U/kg/hr
If thrombotic: thrombectomy, bypass graft, amputation
If embolic: fogarty catheter embolectomy - Consults
vascular consult
follow up questions
- 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 - DDX for limb ischemia
arterial occlusion (thrombotic / embolic)
phlegmasia cerulea or alba dolens
dissection
spinal SAH - 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
- 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) - 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)
HTN CASE
CASE : BP 200/120 and EOD
- MOVID
BW - trop/CK
EKG,CXR
urine tox
US - b lines, volume overload, LVH, possible dissection - 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
- 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 - List for signs of treatable causes of HTN
Pre eclampsia
Pheo
Dissection
Stroke
ICH
Cushings
Thyrotoxicosis
Sympathomimetics
ETOH w/d - What is concerning for hypertensive emergency
MAP >130-135 with EOD (ie HTN encephalopathy, AKI, +trop with symptoms / ECG changes, pulm edema) - 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
DVT CASE
- List ddx for DVT
Bakers cyst
cellulitis
vasculitis
fracture
venous insufficiecny
superficial thrombophlebitis - 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 - Management for DVT
apix 10mg BID X7 D => 5mg BID
rivaroxaban 15mg BID X21D => 20mg daily
preg LMWH - 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
PE CASE
- 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 - 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 - 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 - 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 - EKG findings of PE
Sinus tachy
S1Q3T3
Tall R wave in V1
TWI in V1-4 moost specific
RAD
RBBB
STE in AVR - 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) - 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 - 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)
VASCULAR INJURY
active hemorrhagic inury
- PPE/MOVID
type and screen +/- MTP - 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
- 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 - ABI SBP leg / arm
API SBP injured / uninjured - Describe warm and cold ischemic time
warm ischemic time = 6H (10% - irreversible damage)
cold ischemic time = 12-24H (ischemia without reversible damage is extended) - Describe 3 complications of pseudoaneurysm
rupture
compression of adjacent tissues
embolization - High risk mechanisms for vascular injury
bite
crush
major joint dislocation
shot gun wound
wounds within 1cm to NV bundle - NV bundle associated with artery
axillary = brachial plexus
brachial = median
radial = median + radial
ulnar = ulnar
femoral = femoral
popliteal = tibial nerve