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CCFP-EM > Vascular > Flashcards

Vascular Flashcards

1
Q

Presentations of AAA

A

Incidental
Pain (abdo, flank, chest, thigh, groin or scrotum)
syncope
Hemorrhagic shock
Abdominal mass / fullness
Ureteral Colic
Upper or lower GI bleed - fisutla
High output CHF - Aortovenous or aortocaval fistula

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2
Q

Physical Findings of AAA

A

Pulsatile mass
Triad: pain, mass, hypotension
Distended, large, tender, guarded abdo (blood-induced ileus)
More rare: Bruits, most have normal femorals,
VTE possible - blue toe syndrome, acute lower extremity occlusions

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3
Q

Aneurysm vs Pseudoaneurysm Def’n

A

Aneurysm: Dilation of all three layers (intima, media and adeventitia)
Pseduo: Arterial wall defect that is in communication but can be walled off from true lumen

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4
Q

AAA Common Misdiagnoses

A

mechanical LBP
renal colic
acute MI
prevorated viscous
Acute abdomen (pancreatitis, diverticulitis, cholecystitis, appendicitis, obstruction)
Intestinal ischemia

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5
Q

3 complications of AAA repair

A

Infection
Aortoenteric fistula
Pseudoaneurysm with anastomotic leak

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6
Q

Common complications of endovascular AAA repair

A

Femoral pseudoaneurysm
Infection
Ischemia - spinal cord, gut, renal, extremity
AEF
Chylothorax
Leak

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7
Q

AAA - size criteria

A

< 3 cm normal
> 5 cm - risk of rupture.

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8
Q

AAA Management

A

Surgical Repair is ruptured.
MOVIE - At least 6U immediately available
OR stat
Mortality with rupture is 30-40%

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9
Q

Etiologies of HTN

A

Primary - Idopathic / Essential
Secondary:
*Endo:
- Hyperaldo / Cushings
- Hyperthyroid
- OCP Use
- Pheochromocytoma
*Pulmonary:
- OSA
*Renal:
- RAS
- Nephrotic / Nephritic
- DM nephropathy
- PCKD
*Toxic / Metabolic:
- Sympathomimetic
- EtOH use chronic
*Vascular
- Atherosclerosis
- Coarctation of Aorta

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10
Q

Aortic Dissection Risk Factors

A

Family Hx (3x)
Bicuspid Valve
Connective tissue
Male
Hx of CV Surgery

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11
Q

Classifications for AD

A

DeBakey
- Type I - Arises in ascending and includes descending
- Type II - Ascending only
- Type III - Descending only
Standford
- Type A - Ascending
- Type B - Descending (Below)
* Below the L subclavian

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12
Q

AD Presentation and Signs

A

Tearing pain (Thunderclap ~ 50%)
Radiation to back
New neuro deficit
Migratory (only 17%)
Evolving symptoms

Signs:
New aortic regurg
Pulse deficit
BP discrepancy
Signs of tamponade (Beck’s: Hypotension, distended neck veins, muffled heart sounds)
Neuro findings - stroke, peripheral deficits
Widened mediastinum
Inferior or RV/posterior MI (Dissection in RCA)

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13
Q

Aortic dissection Investigations

A

Trop
D-Dimer
CXR
ECG
Advanced imaging

CT-A Diagnostic Gold standard
TEE good sensitivity
TTE / POCUS less sensitive

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14
Q

CXR Findings of AD

A

Wide mediastinum
Loss of PA window
Loss of Aortic knuckle
Esophagus displaced to R.
Trachea to R
L mainstem down
Pleural effusion
Apical Cap
NG deviated to R

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15
Q

Role of D-Dimer in Aortic Dissection

A

94-99% sensitive
False negative: false lumen, intramural hematoma, chronic, young age

96% sensitive with cut-off of 500

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16
Q

Aortic Dissection Pathway for Testing

A

High-risk physical exam findings
Risk factors
High-risk pain features
AAS most likely dx

Low - no testing
Moderate - D-Dimer
High Risk - CT-A

Practical Steps:
1. Get hx to rule out high risk features
2. Examine for new murmurs, neurodeficits, pulse deficits
3. Check BP for hypotension
4. POCUS
5. XR
6. ECG and Trop

STEMI - angio
Stroke - CT/CTA
Calculate risk based on findings.

17
Q

Aortic Dissection Treatment

A

Pain - Fentanyl
HR - Labetalol or Esmolol. If asthma can give Diltiazem or Verapamil
Then Nitroprusside or IV Ace inhibitor (Enaliprilat)

Type A: emergent surgery. med mgmt in ED. May need pericardiocentesis.
Type B: Medical management in ICU. Vasc Sx Consultation.

18
Q

5 Causes of Hypotension in AD

A

Pseudo hypotension.
Tamponade / Pericardial Effusion
STEMI
Aortic regurg
Aortic Wall Rupture (no chest tube)

19
Q

AAA leaks - 5 types

A

1 - At waist or ankles
2 - Branch vessel
3 - Leakage at anastomosis between stent components
4 - Leakage through graft material
5 - NYD

20
Q

Differential for DVT

A

Venous insuffiency
Baker’s Cyst / Rupture
Cellulitis
SVT
Vasculitis
Fracture
Lymphedema
Hematoma
Calf Strain

21
Q

Causes of elevated D-Dimer

A

Trauma
Sepsis
VTE
Aging
Recent Sx
Stroke
MI
Bed Rest / casting
Malignancy
Pregnancy

22
Q

Wells’ Criteria DVT

A

PE:
Pitting edema to symptomatic leg only
Tender to palpation
Entire leg swollen
Superficial non-varicose
Calf Swelling > 3 cm

Hx:
Previous DVT
Recent Sx / Bedridden
Active cancer
Plaster Immobilization

23
Q

Risk Factors for PE

A

Inherited thrombophilia
Cancer
Pregnancy
Prior DVT/PE

Surgery or trauma

Dsypnea
Hemoptysis
Pulse > 100
O2 < 95%
Unilateral limb swelling

24
Q

Types of PE

A

Low risk - labs and vitals normal
Non-massive - BP > 90, elevated trop/dimer, RV dysfunction, SpO2 < 94%
Submassive - Moderate distress, new RBBB, Sp)2 < 90%
Massive - Hypotension < 90 sBP for > 15 minutes, distress, cardiac arrest

25
Q

ECG and CXR Findings of PE

A

New RBBB, A. Fib, Sinus tach, Symmetric TWI in V1-V4, S1Q3T3
Unilateral basilar atelectasis, Hampton’s Hump, Westmark sign (decreased BV on affected side)

26
Q

Wells PE

A

Hx: Past PE/DVT, recent Sx or immobilization, active Ca
Physical: Signs of DVT, hemoptysis, HR > 100
Gestalt: Most likely Dx

27
Q

PERC

A

Cannot rule rule out if:
Age > 50
OCP
HR > 100
O2 sat < 95% on room air
Hemoptysis
Unilateral leg
Hx of DVT/PE
Recent Trauma / Sx

28
Q

What are Phlegmasia Cerulea Dolens and alba dolens

A

Blue leg due to massive iliofemoral DVT. (Alba - white)

29
Q

Year’s Criteria

A

Signs of DVT
Hemoptysis
PE most likely

If none of above D-Dimer < 1000 Rule out
If any of signs above - D-Dimer 500
If signs of DVT - US.
- If normal Dimer < 500
- If abnormal - Treat

30
Q

Differential for peripheral arterial insufficiency

A

Venous insufficieny
Neuropathic ulcers
Nocturnal muscle cramps
Aorto-occlusive disease
Vasculitis
Spinal stenosis

31
Q

3 Disorders of Abnormal Vasomotor Response

A

Reynauds Disease (Phenomenon when 2nd disease present)
Benign Livedo Reticularis
Acrocyanosis
Primary Erythromelalgia

32
Q

Reynaud’s Disease Characteristics

A

Cold or emotional upset
Bilateral symptoms
No / minimal tissue loss
No systemic disease for Reynaud’s Phenomenon
2 years of Symptoms

Classics - White - Purple - Red

Tx: CCB for symptomatic relief

33
Q

3 Types of Visceral Aneurysms

A

Splenic Artery: (most common in young pregnant females)
- Should be coiled
- 70% mortality if rupture

Hepatic Artery: Stem from atherscerosis, infection, post trauma, polyarteritis
- Men > 60
- Usually asymptomatic - need to be treated when found

SMA: 60% by non-hemolytic strep from infective endocarditis
- Usually < 50, IV drug users
- Upper abdo angina

34
Q

3 Types of Thoracic Outlet Syndrome

A

1) Compression of brachial plexus
2) “ “ subclavian artery
3) “ “ “ vein
Or all of the above

95% with compression of plexus

35
Q

Types of Infective Aneurysm

A

Mycotic - Endocarditis, strep usually or staph
Atherosclerotic
Pre-existing aneurysm
Post-traumatic

CCFP-EM (20 decks)

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