Vascular Flashcards
What is this?
How can it be confirmed and rationale for this
What are the management priorities
**Phlegmasia cerulea dolens **
Confirm via:
* US lower limb - non compressable deep veins, no variance tp doppler pulse vein
* CT Venogram - assess clot burden and degree of clot. Map for intervention
Management
* Analgesia - dose and route
* Anti cogulation heparin infusion with loading
* Vascular surgery for embolisation
describe image and most likelt diagnosis
AAA approx 8cm
likely a bleed in the wall as fresh blood is white
what is the role of a CT in a ruptured AAA
if in a centre where endovascular is used CT is essential for planning and stent sizing
if laparatomy then it just delays time to theatre
Ruptured AAA
what are the steps in management whilst awaiting to go to theatre
- Urgent cross match/FFP/platelets
- permissive hypotension about 90mmhg
- analgesia eg fent or morphine
- explain plan to patient/family
collapse and abdo pain
?diagnosis
AAA
with an US confirmed AAA what would influence decision to do a CT
- are they shocked - if so then no
- proximitiy to CT
- pre surgical planning
- co-morbid status of patient
What are the definitive treatment options for AAA
Open repair
endovasculat stent
palliation
chest pain
what are the important features
inferior stemi
STE 2,3,avf (3>2)
reciprical changes
hyperacute t waves
what are the CXR features of aortic dissection?
- Widening of the superior mediastinum
- Dilatation of the aortic arch
- Change in the configuration of the aorta on successive CXR
- Obliteration of aortic knob
- Double density of aorta (suggesting true and false lumen)
- Localised prominence along aortic contour
- Displacement of trachea to right
- Distortion of left main stem bronchus
- Pleural effusion
- Cardiomegaly
what featurs of bedside echo would differentiate acute MI from aortic dissection?
MI
* Regional wall motion abnormality
* hypokenesis
**
Aortic dissection**
* pericardial effusion
* dilated IVC (tampanade)
* Intimal flap
* AV incompetence
what are the classifications of aortic dissections?
Stanford
o A: Ascending aorta with or without descending
o B: Descending aorta only (distal to origin of left subclavian)
What is the management of acute aortic dissection
- Resus bay
- 2 large cannulas and send bloods and cross match
- IV analgesia
- IV rate control to 60 eg metoprolol
- IV BP control under 140 eg GTN
- Art line
- urgent transfer to centre which can have capacity for surgical fixing
major abnormality and diagnosis in chest pain
Large pericardial effusion
Thoracic aortic dissection with pericardial effusion, impending tamponade
what are the PRN end of life meds
- Analgesia: morphine 1-2 mg subcut Q3H or hydromorphone or fentanyl
- Sedative: midazolam 2.5 mg Q3H
- **Anti-secretions: **hyoscine 400mcg Q3h or glycopyrrolate
what are the life threatening complications of aortic dissection
pericardia tampanade
stroke
MI
Severe AR
what are the risk factors for aortic dissection
- hypertension
- bicuspid aortic valve
- male
- increasing age
- CTD eg Ehlor danlos
- coarctation of aorta
what does aortic dissection cause hypotension
- pericardial tampanade
- aortic incompetence from aortic root dissection
- iatrogenic from drugs given
diagnosis
Type A aortic dissection
what are the clinical signs of aortic dissection
- loss of pulses
- neurology - from stroke or spinal ischaemia
- AR murmur
- becks triad - signs of tampadane
- significant patient distress
type a thoracic dissection
4 findings and diagnosis
- necrotic 2nd toe
- pus
- cellulitis
- erythema with blister
Diagnosis
Diabetic foot infection with necrotic toe
diabetic foot:
Investigations and justifications
what are the causes of limb ischaemia with examples?
- thrombotic - atheroscletoric plaque
- embolic - AF, CCF, AAA
- other - dissection. septic embolic
Society for vascular surgery catergoes for limb ischaemia
what are the medications for limb ischaemia
- IV fentanyl aliquots and titrate to pain
- heparin infusion titrate to APTT
what are the interventional options for limb ischaemia
- Catheter-directed thrombolysis
- Embolectomy
- Bypass
features of limb ischaemia that suggests arterial embolism over thrombosis - on history
- sudden symptoms
- AF
- no history of atherosclerotic disease
- endocarditis
- atrial myxoma
features of limb ischaemia that suggests arterial embolism over thrombosis - on exam
presence of AF
murmurs
clinical signs of endocarditis
good proximal pulses
clear site of demarcation
more extensive gangrene or limb threatened
with limb ischaemia what are the complications of reperfusion
hyperkalaemia
compartment syndrome
renal failiure
rhabdo
re-occlusion and ischaemia
hypotension
- Embolic – from AF
- Thrombotic
- Traumatic – penetrating injury
- Iatrogenic – IVC or IV drug arterial injection
- Aortic dissection extending to subclavian artery
- Neuro – spinal SAH
- Thoracic outlet syndrome
two findings/signs
What is the most important test?
- Pembertons sign
- goitre
CT chest ?mass
what is pembertons sign and what does it suggest
engorged neck veins when raising arms
SVC obstruction
what are the causes of SVC obstrutcion
- mediastinal mass - lymphoma, thymoma, lung Ca,
- retrosternal thyroid
- aortic aneurysm
- indwelling venous catheter
- TB
key findings and diagnosis
widened mediastinum
loss of aortic knob contour
pleural effusion
Aortic dissection
AAA
main abnormalities and cause
- Relative hypoxia with A-a gradient of approx 130 – likely causes include aspiration pneumonia/pleural effusion
- HAGMA with anion gap 19 – likely cause hypoperfusion of gut from aortic dissection (this
supported by raised lactate)
Raised creatinine and elevated potassium – likely involvement of renal A in dissection
severe abdo pain
findings
AAA
* Significant intraluminal clot
* Suggestion of rupture
what is a massive transfusion in adult patient
over one whole blood volume in 24 hours or half in 4 hours
what are the target parameters with massive transfusion
young with chest pain
what are the abnormal findings
sinus tachy
RBBB
finding
saddle embolus
- define
massive
submassive
nonmassive PE
* Massive PE
Acute PE + haemodynamic compromise (no longer defined by size)
* BP < 90 for 15min
* Vasopressor requirement
* Pulseless
* Submassive PE
Acute PE, not haemodynamically compromised but:
* Right heart strain (ECG / Echo / BNP)
* Troponin Leak
-
Non-massive PE
Acute PE + none of above
what are the 8 featurs of the PERC
treatment for PE peri arrest
Improve oxygenation: HFNO2 50L/min, titrate fio2 to target SaO2 92-96%
Vasopressors: Noradrenaline infusion target BP 90-100
Systemic thrombolysis: Alteplase IV
* Deteriorating or arrest = 50mg alteplase bolus
- Stable 100mg (10mg bolus, 90mg over 90min)
what are the indications for thrombolysis in PE
cardiac arrest
massive PE with hypotension
Right heart strain or troponin leak
extensive clot burden
hypoxia
what are the causes of a false negative d dimer
small clot burden
mature thrombus
recent bleeding
cancer
collection error
components of wells score
What are the ECG findings in PE
Sinus tachy
PR depression
RAD
RBBB
dominant R wave V1
LAD
atrial arrhytmia
