PAD #2 Flashcards
What is an abnormal ABI?
<0.9
What does an immediate occlusion of bloddflow feel like?
No pulses
immediate pain
like putting a rubber band around your finger
Essentials of diagnosis for an acute arterial occlusion of a limb?
Sudden pain in limb + absent limb pulses
Some degree of neurologic dysfunction with numbness, weakness, or complete paralysis
Loss of light touch sensation requires revascularization within 3 hours to save limb
Window of revascularization
3-6 hours
greater than that = more likely to lose a limb
Difference between a thrombus and an embolus
Result of THROMBUS or EMBOLUS
Thrombus - stable atheroma with fibrous cap suffers plaque rupture leading to thrombus development and acute occlusion
Patient typically has hx of intermittent claudication
Presentation may not be as dramatic if h/o chronic PAD due to development of collaterals
Embolus - large emboli most commonly come from the heart
Afib is most common cause
Atherosclerosis of larger vessels may suffer plaque rupture, creating a thrombus, which can break off and travel to smaller vessels (embolus)
Atrial myxoma
tumor in the heart (more on this later)
What are the 6 P’s pf an acute occlusion
Pallor
Pain
Pulseless
Paralysis (late stage, but need immediate)
Polar / Poikilothermia (white patchiness of tissue)
Paresthesias
can happen as quick as 1 hour
How do you diagnose acute occlusion
Typically clinical
Can do a doppler
DO NOT waste time for CTA or MRA scan
TIME IS TISSUE
you may also consider
EKG
CBC PT/INR, PTT (for surgery prep)
Echo (LATER) if patient has no other risk factors
BMP, ABG
What is a bubble study
Echo
Blood flow
Check for Patent foramen ovale
(hole is between the RV and LV)
What is CRUCIAL for treating acute occlusion?
IMMEDIATE revascularization within 3-6 hours
IV heparin bolus then continuous and then revasculartization in that order (surgery includes endovascular or open-surgical)
Once stable, what do we do for acute peripheral thrombus?
source must be determined → thrombus vs embolus
If due to PAD thrombus - treat as you do other PAD patients
If due to embolus, must determine the source and treat underlying cause
Most require warfarin (Coumadin) for at least 3 months, or longer, with goal of INR of 2.0 to 3.0
Why is acute more likely to cause amputation than chronic?
Chronic has time to develop collateral bloodflow
A 75-year-old man presented to the emergency department with a 4-week history of progressive right foot pain that occurred at rest. He also had calf muscle pain that worsened when he ambulated. His medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient reported no significant surgeries in the past. He was a former smoker, who stopped smoking 5 years ago; he smoked 1 pack of cigarettes per day for 50 years before stopping. He denied use of alcohol or any other recreational drugs. Medications were low-dose aspirin, metformin, amlodipine, lisinopril, and rosuvastatin.
RED flags of this patient
On physical examination, vital signs were within normal limits. The right foot was cold. There was a shallow 3.5-cm × 2.8-cm ulceration on the medial aspect of the right first metatarsal. Pedal pulses were diminished on the left and absent on the right. Right foot sensations and muscle strength were intact. The ankle-brachial index (ABI) was calculated as 0.65 on the left and unobtainable on the right.
How would you manage this case?
Tissue damage at rest
every risk factor of PAD
older gentlemen
Manage:
He has an acute peripheral artery disease
Bolus of heparin
Vascular surgery on board
severe occlusion for ABI is?
<0.4
What is an aneurysm
ballooned vessel
What is an AAA
abdominal aortic aneurysm
What are the 4 essential of diagnose of AAA
- Most AAAs are asymptomatic until rupture
- 80% measuring 5 cm are palpable; threshold for treatment is 5.5 cm
- Back or abdominal pain with aneurysmal tenderness may precede rupture
- Rupture is catastrophic: excruciating abdominal pain that radiates to the back; hypotension (BP tanks because the vessel is messed up like crazy)
When is a abdominal aorta considered AAA?
> 3 cm
rare to rupture > 5 cm
Where are most AAA?
Aneurysms usually involve the aortic bifurcation and often involve the common iliac arteries
What is a fusiform AAA
A lot of false lumen that gets stuck and sticky
What is a Saccular AAA
also false lumen that is clotting
Presentation of AAA
Most are asymptomatic, but may have mid-abdomen and often radiating to the lower back
Symptoms of AAA
Aneurysmal expansion may cause pain that is mild to severe, located over the mid-abdomen, and often radiating to the lower back
May be constant or intermittent
Exacerbated by even gentle pressure on the aneurysm sack
Most have thick layer of thrombus lining aneurysmal sac
Distal embolization of thrombus is rare
What is an abnormal CT in AAA?
AA very close to the thoracic wall
Presentation of AAA rupture
The sudden escape of blood into the retroperitoneal space causes severe pain, a palpable abdominal mass, and hypotension.
Free rupture into the peritoneal cavity is lethal
Diagnostics of AAA
would only be performed in patients undergoing surgical repair
CBC, BMP, PT/INR, PTT
Abdominal ultrasonography is the diagnostic study of choice for initial screening for the presence of an aneurysm
CT scans provide a more reliable assessment of aneurysm diameter
Done when the aneurysm nears the diameter threshold (5.5 cm) for treatment
Contrast-enhanced CT scans show the arteries above and below the aneurysm, which is essential for surgical planning
