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ACC > Vascular Core Conditions > Flashcards

Vascular Core Conditions Flashcards

1
Q

What is temporal arteritis?

A

A Granulomatous vasculitis of large & medium sized arteries
Affects branches of the external carotid artery
Most common form of systemic vasculitis in adults

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2
Q

What are the causes of temporal arteritis?

A

Genetics

Environmental triggers

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3
Q

What are the RFs for temporal arteritis?

A 
>50
Female
Genetic predisposition
Smoking
Atherosclerosis
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4
Q

What are the investigations for temporal arteritis?

A 
Bloods:
ESR >50mm/hour
CRP: Elevated
FBC: Elevated
Temporal artery biopsy
Temporal artery USS
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5
Q

How is temporal arteritis managed?

A

No visual signs: Prednisolone 1mg/kg/day orally 4weeks taper dose over 6-12months
Visual signs: Methylprednisolone 1g IV/day for 3days with IV pulse therapy
Ongoing: Aspirin 75mg/daily, Prednisolone 1mg/kg/day orally for 4weeks taper over 6-12months

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6
Q

Where are most DVTs found?

A

Lower limb:
Anterior tibial vein
Posterior tibial vein
Peroneal vein

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7
Q

What is the pathophysiology of a DVT?

A

Virchow’s Triad:
Hypercoagulable state
Vascular wall injury
Circulatory stasis

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8
Q

What are the signs & symptoms of a DVT?

A 
Pain
Swelling/oedema
Homans sign (pain in calf on dorsiflexion of foot)
Warmth & erythema
Local tenderness
Signs of PE
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9
Q

How is a DVT investigated?

A

D-Dimer
Well’s Score
Duplex USS: Within 4hours of request (if not give 24hr dose of anticoagulant)
Pregnant/post-partum: Imaging NOT a D-Dimer
Contrast Venography

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10
Q

Why is a D-dimer test not a great test?

A

High sensitivity
Low Specificity
May be raised in: Cancer, Infection, Post-op, Following trauma or haemorrhage

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11
Q

What are the outcomes of the Well’s Score?

A

DVT unlikely: With -ve D-Dimer can discharge, +ve D-Dimer = imaging
DVT likely: Further imaging required

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12
Q

What is the treatment for a DVT?

A

Anticoagulation: Rivaroxaban

Cancer patients: LMWH

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13
Q

Define acute ischaemic limb?

A

Any sudden decrease in limb perfusion causing potential threat to limb viability
Symptoms <2 weeks

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14
Q

What are the causes of acute limb ischaemia?

A 
Peripheral arterial disease
VTE
Vasculitis
Popliteal entrapment syndrome
Compartment syndrome
Graft Occlusion
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15
Q

What is the prognosis of acute limb ischaemia?

A

Limb salvage 70-90%

Amputations usually from thrombotic occlusions

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16
Q

Where is the most common place for emboli in acute limb ischaemia to arise from?

A

80% from the heart
Composed of platelets
Other: Proximal arterial disease (aneurysm or stenoses)- poorer prognosis as harder to treat

17
Q

What are the signs & symptoms of acute limb threatening ischaemia?

A

Pain: At rest worse in most distal part of the limb, relieved on hanging leg over bed side, claudication, pain worse on passive muscle movement (compartment syndrome)
Pallor: White colour, chronic critical ischaemic limb= pink (due to compensatory vasoD), sunset foot
Paraesthesia: 50% of cases, seen before motor nerves affected
Paralysis: Poor prognostic sign element of irreversibility
Perishingly cold
Pulselessness: Unreliable
Fixed mottled skin: Irreversible ischaemia

18
Q

What bedside examination is useful to check for limb ischaemia?

A

Buergers test: Pallor on elevation of limb & erythema on lowering

19
Q

What investigations should be done in acute limb ischaemia?

A

Arterial Doppler signals
Heart auscultation: Check for arrhythmias
Abdo assessment: AAA
Affected leg: Inspect, palpate, auscultate
ABPI: Assess severity
Bloods: FBC, U&E, Glucose, Creatinine kinase, Clotting, G&S
ABG
Imaging: MR/CT angiography

20
Q

How is ABPI calculated?

A

Pedal Systolic pressure / Brachial artery pressure

21
Q

What do the ABPI scores mean?

A

Normal: 1-1.2
Claudication: 0.6-0.8
Critical ischaemia: 0.2-0.4

22
Q

How is acute limb ischaemia managed generally?

A 
IV morphine
Oxygen
5000u IV unfractionated Heparin
IV fluids 
Refer: Vascular specialist
23
Q

What is the definitive management for acute limb ischaemia?

A

Cat I: VIABLE LIMB, analgesia, oxygen, heparin, imaging within normal working hours, plan treatment
Cat IIa: THREATENED LIMB, oxygen, analgesia, heparin, immediate imaging,
Cat IIb: THREATENED LIMB & CANNOT WAIT OVERNIGHT, oxygen, analgesia, heparin, if possible imaging before theatre, DO NOT delay intervention, urgent revascularisation (op or thrombolysis)
Cat III: IRREVERSIBLE ISCHAEMIA LIMB NOT SALVAGEABLE, DO NOT attempt revascularisation, Tx (amputation, palliation)
Thrombolysis: Alternative to surgery, Streptokinase

24
Q

Why should revascularisation not be attempted in catIII limb ischaemia?

A

Likely to kill patient
Massive release of potassium, creatine kinase, myoglobin, lactate, oxygen free radicals from ischaemic tissue
Can cause renal failure, myocardial toxicity, multi-organ failure

25
Q

What are the contra-indications to thrombolysis?

A 
Bleeding/ s. bleeding tendency
Pregnancy
CVA/TIA <2months ago
Intracerebral tumour/AVM/aneurysm
Surgery <2weks
Previous GI bleed
Trauma <10days
26
Q

Where do most AAA occur?

A

90% below renal arteries

27
Q

What are the causes of AAA?

A

Multifactorial
Altered tissue metalloproteinases
Atherosclerosis

28
Q

What are the signs & symptoms of a AAA?

A

Asymptomatic
Abdo/back pain
Pulsatile, expansile mass
Trash feet: Dusky discolouration of digits secondary to emboli from aortic thrombus
RUPTURE: Severe sudden pain radiating to the back, death, hypoT, tachycardia, profound anaemia, signs of shock

29
Q

What are the investigations for a AAA?

A

Clinical: pt >50 w/acute onset abdo/back pain AND hypoT
pt with known AAA either abdo/back pain OR hypoT/collapse
USS: x1.5 normal size
CT/MRI: Relation to other structures
ECG
Bloods/ABG: U&E, Creatinine, amylase, troponin, ESR, CRP, FBC
Aortography

30
Q

How is a ruptured AAA managed?

A 
>75% mortality before reaching hospital
14G IV access &amp; fluids
Blood products 
Intubation
Central Venous Line
Theatre: EVAR repair
31
Q

How is a non-ruptured AAA managed?

A 
>5.5cm treated
Open laparotomy
Prosthetic segment
Theatre: EVAR
Pre-op: Beta blocker (Metoprolol, Atenolol), statin, smoking cessation
32
Q

What is the massive haemorrhage protocol?

A
  • Administer Tranexamic Acid within 1 hour
  • RESUS: Cardiac monitoring, prevent hypothermia, consider 10mls CaCl 10% over 10mins, cryoprecipitate x2
  • Call for help: Take bloods & send to lab, order massive haemorrhage pack1 (4u FFP & 4u Red cells), reassess, order massive haemorrhage pack2 (4u red cells, 4u FFP, 1dose platelets)
  • Stop the bleed: Direct pressure, stabilise#, surgery, Vit K & prothrombin, reversal of NOAC, cell salvage if available
33
Q

What is the management of peripheral arterial disease?

A

Atorvastatin 80mg
Clopidogrel
Exercise
Severe PAD: Angioplasty, stenting, bypass surgery

34
Q

What 3 patterns are seen in PAD?

A

Intermittent claudication
Critical limb ischaemia
Acute limb-threatening ischaemia

ACC (21 decks)

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