Vascular Emergencies Flashcards
Causes for acute arterial occlusion
Embolus
Thrombosis
Direct trauma to arteries
will lead to distal ischemia to the occlusion if left untreated
Embolic occlusion
Caused by dislodgment of intravascular thrombus That travels dismally and occludes a small artery
- usually originates in the left ventricle of the heart but can come from anywhere
history of arrhythmias, MI or valvular heart disease are often suggestive of acute peripheral ischemia
Types of emboli
Cardiac: originate in the left atrium often in patients with:
1) current atrial fib/mitral valve disease
2) history of recent MI or ventricular aneurysm
Vascular: originate on luminal surfaces in vessels that are atherosclerotic. Often in patients with
1) atherosclerosis
2) high cholesterol patients
Tumor: rare but most commonly caused by atrial myxomas
Thrombosis occlusion
Caused by plaque disruption and resultant clot formation from an atherosclerotic vessel. Often found in patients with history of:
1) peripheral vascular disease
2) claudication
3) progressive pain at rest
4) non healing wounds of the distal extremities
Takes time to present and shows intermittent claudication with it
- results in ischemia, irreversible anesthesia, paralysis and tissue infarction
Clinical findings of thrombi/emboli occlusion
Symptoms and signs:
- extremity pain
- paresthesia
- paralysis of limbs (if prolonged)
- pale/cool/CYANOTIC
- lower or absent pulses
Imaging studies:
- angiography will confirm affected limb
- can also use CTA, MRAs and arterial duplex ultrasonography
Treatment for embolism/thrombi occlusion
1) Receive a general/vascular surgery consultation immediately
- if surgery required, its usually fogarty embolectomy
2) same time or immediately after,Insert a IV catheter and begin IV heparin as soon as possible unless contraindicated
3) Obtain labs of CBC, PT and PTT times as well as blood chemistries specifically blood types.
Acute peripheral ischemia “blue toe syndrome”
Symptoms
- abrupt onset of small painful area on affected digit
- affected area is tender cool and CYANOTIC
- will be ASYMMETRIC w/ possible livedo reticularis (swollen mottled reticulated vascular pattern w/ purplish discoloration of the skin)
- is an emergency
Treatment:
- treat proximal source of emboli with direct IV heparin or vascular surgery
Acute peripheral ischemia due to venous occlusion in whole extremity “phlegmasia cerulea dolens”
Symptoms:
- massive acute swelling of affected leg
- leg is edematous and doughy consistency
- cyanosis and gangrene
- color flow Doppler ultrasound or venography confirms diagnosis
Treatment:
- immediate IV heparin at full dose
- immediate general or vascular surgery consultations (thrombectomy) if Heparin Tx doesnt work or is contraindicated
Acute visceral intestinal ischemia
Symptoms
- severe non-localized abdominal pain w/ hypotension
- history of intestinal angina
- pain out of proportion to physical findings
- grooms intestinal bleeding
- abdominal distention
Imaging/labs to confirm
- mesenteric arteriography or CT
- elevated leukocytes, metabolic acidosis and elevated lactate
Treatment:
- IV with saline and blood to combat hypotension
- stop bleeding with vascular surgery
Ruptured AAA
Symptoms
- sudden onset of abdominal/flank pain
- pulsation abdominal mass
- hypotension
Screening and labs to confirm
- bedside ultrasound
- CT scan
- low hematocrit w/ ECG signs of STEMI
Treatment:
1) consult surgery since this is needed (100% mortality if no surgery, 40% if surgery)
2) very rapid treatment of hypotension and shock before surgery if present( use oxygen and saline and blood perfusion)
3) if HTN is present DONT treat it
TAAs and thoracic dissection
Symptoms:
- abrupt 10/10 chest w/ radiation to the back or upper abdominal
- aortic murmur from aortic regurgitation may be heard
- may hear muffled heart sounds (cardiac tamponade)
- weak or pulselessness pulses
- syncope
- paralysis (only if carotid has been dissected as well)
- hypertensive
Imaging and tests to confirm
- chest CT or MRI
- trans esophageal echo (TEE)
- ECG often shows anterolateral STEMI characteristics
Treatment: *GET SURGERY CONSULTATION* - immediate treatment of hypertension Done via: 1) IV esmolol (to test BB use NOT to treat) 2) IV labetalol 3) nicardipine (if BBs are contraindicated or not tolerated) 4) nitroprusside (if all else fails)
- also use fentanyl/morphine to control pain*
Common risk factors for TAA and AAA
HTN
Trauma
Pregnancy
Marfan syndrome
Ehlers-Danlos syndrome
Turner syndrome
Cocaine/elicit drug abuse
Coarctation of the aorta
Valve stenosis/replacements (especially aortic)
Intra-aorta catheterization
peripheral arterial aneurysms
Symptoms
- pulsation mass on physical examination
- Pain out of proportion
- intestinal angina
- edema/swollen leg w/ cyanotic apperance
- may have high femoral BP
- most common areas for peripheral arterial aneurysms are femoral, popliteal, splenic arteries and the SMA
Imagining and tests to confirm:
- ultrasound
- increased lactate/metabolic acidosis and increased WBC counts
- arteriography defines where the cutoff begins
Treatment:
- IV heparin and notify surgeon immediately for surgery (if heparin doesnt stop it)
Lower DVT
Symptoms:
- unilateral swelling, warmth and redness of the affected limb
- pain in the affected limb that worsens overtime and does not respond to meds
- (+) homan sign (pain in posterior calf from dorsiflexion
Imaging and labs to confirm:
- ultrasounds of the leg confirm however venography is the gold standard if possible
- D-dimer elevation can help confirm but is not specific
Treatment:
- start IV heparin (LMW) or factor 10 inhibitors if heparin contraindicated
- use surgery if this cant be fixed
- requires heparin or factor 10 treatment for life usually
Superficial thrombophlebitis
Symptoms:
- pain/tenderness/induration and redness along the vein
- no edema in extremities
- may feel like a string of beads
Treatment:
- only treat symptoms if no complication (will run its course)
- surgery and parenteral antimicrobials if complications occur (becomes septic or moves to a bigger vein)
