Surgery B - aneurysm & the acutely ischaemic leg (vascular) Flashcards
72 y/o male pc back pain. onset 8hrs ago, 8/10 intensity over past 2 hours. mid lumbar pain is bilateral and continuous. does not improve when position changed.
pmh: HTN, previous MI, angioplasty 5 years ago. brother had repair of AA 3 years ago.
SH: 60 pack year hx
deep indiscreet mass with pulsatility found on deep palpation.
differential diagnoses?
AAA
renal colic
abdominal pathology
- diverticulitis
- pancreatitis
- IBD
- IBS
- GI haemorrhage
- appendicitis
classic triad of ruptured AAA?
- flank or back pain
- hypotension
- pulsatile abdominal mass
immediate investigations / treatments for AAA?
- high flow oxygen
- IV access (2x large bore cannula)
- urgent FBC, U&Es, clotting, G&S, ECG
treatment options for AAA?
open repair
EVAR
- better long term results and lower costs
complications likely from emergency repair of AAA?
- open bleeding
- infection
- cardiac/resp/renal compromise
- bowel/limb ischaemia
- stoma
- amputation
- stroke
- DVT/PE
- death
57 y/o male
pc: R leg pain, numbness for 5hrs
associated lightheadedness and nausea, without chest pain
difficulty moving his right leg. no hx trauma.
pmh: recent MI, smoking, HTN but not DM or hyperlipidaemia.
Dx: aspirin, beta blocker, ACE inhibitor, diuretic
OE: 140bpm, abdo soft and palpable femoral and pedal pulses in left leg. no femoral or pedal pulses in R leg.
right leg: cool, mottled, with decreased sensation and decreased motor function.
differential diagnosis?
acute limb ischaemia
what features would suggest acute ischaemic limb ischaemia
6Ps
- paraesthesia, perishingly cold, pulselesness, pain, paralysis, pallor
- no tissue loss
- contralateral pulses present
immediate management of acute ischaemic limb ischaemia?
- oxygen
- IVI
- blood
- ECG
- treat t.cardia
- heparin bolus and infusion
what investigations are indicated in acute limb ischaemia?
- routine blood (serum lactate to assess level of ischaemia)
- thrombophilia screen, G&S
- doppler, US both limbs
- followed by CT angiogram
Discuss management of acute limb ischaemia?
- initial management
- complete arterial occlusion —> irreversible tissue damage within 6hrs
- high flow oxygen + IV access
- therapeutic heparin dose - conservative
- considered in Rutherford 1 and 2a
- prolonged course of heparin - surgical
- embolectomy
- thrombolysis
- bypass
An important complication of acute limb ischaemia is reperfusion injury; sudden increase in capillary permeability can result in:
Compartment syndrome
Release of substances from the damaged muscle cells, such as:
—> K+ ions causing hyperkalaemia
—> H+ ions causing acidosis
—> Myoglobin, resulting in significant AKI
describe irreversible limb ischaemia and the management?
- mottled, non-blanching appearance with hard woody muscles
- requires urgent amputation
