Vascular Emergency Flashcards
Describe acute limb ischemia.
Acute limb ischemia is a sudden decrease in blood flow to a limb, leading to potential tissue damage and loss. 5 p
What is the source common cause of embolism in vascular surgery?
The most common source of embolism in vascular surgery is the heart.
Where is the most common site of embolism in vascular surgery?
The most common site of embolism in vascular surgery is the bifurcation of the femoral artery.
What is the earliest sign of acute limb ischemia?
The earliest sign of acute limb ischemia is pallor.
Most common complaint………acute limb schema
pain
What is the latest sign of acute limb ischemia?
The latest sign of acute limb ischemia is paresis.
Define the 6 Ps in the clinical picture of acute limb ischemia.
The 6 Ps in the clinical picture of acute limb ischemia are pallor, pain, pulselessness, parathesia, paresis, and poikilothermia.
How does acute limb ischemia typically present in terms of age and gender?
Acute limb ischemia typically presents in old age males.
Describe the onset of acute limb ischemia.
The onset of acute limb ischemia is sudden.
What is a common clinical scenario in exams involving acute limb ischemia?
A common clinical scenario in exams involves a patient with a previous history of myocardial infarction presenting with sudden severe pain in the leg.
Describe the importance of fast duplex in the diagnosis of a condition.
……the best but delay diagnosis
Fast duplex is crucial for quick and accurate diagnosis.
Angiography
What is the recommended treatment for the condition mentioned in the content?acute limb ischemia
Treatment includes morphine, hydration, IV heparin, and possibly embolectomy.
Define acute compartment syndrome.
Acute compartment syndrome is characterized by marked swelling of a limb leading to compression of vessels and ischemia.
How should acute compartment syndrome be managed?
Immediate fasciotomy is the treatment of choice for acute compartment syndrome.
What ECG finding is associated with hyperkalemia?
Hyperacute T wave is an ECG finding in hyperkalemia.
What is the immediate treatment for hyperkalemia?
Immediate administration of calcium gluconate is recommended for hyperkalemia.
Describe the causes of arterial injuries.
Causes can include penetrating injury, fractures, and complications following cannulation.
What is the first step to manage arterial injuries?
The first step is applying pressure to stop bleeding.
What is the definitive treatment for arterial injuries?
Surgery is the definitive treatment.
What is the initial step to manage a patient with swelling at the femoral area after recent catheterization?
Pressure
Define chronic ischemia in the context of arterial injuries. What is causes it??
Chronic ischemia is a condition commonly caused by atherosclerosis.
How does intermittent claudication present in arterial injuries?
Early
Intermittent claudication is an early symptom characterized by leg pain that occurs with activity and improves with rest.
Describe the symptoms of rest pain in arterial injuries. Most serious….
Rest pain worsens with elevation of the legs, decreases when hanging the legs, and is typically most severe at night.
What are some other symptoms associated with arterial injuries?
Other symptoms can include hair loss, nail loss, cold limbs, and color changes in the affected area.
What is the most important sign indicating arterial insufficiency?
Rubor upon dependency is a crucial sign of arterial insufficiency.
CAD
First test……..
index…vvvvvvvvvv imp Normally more than 1
If less than 0.5….
Duplex………
Arteriography…….
First test……..ankle brachial pressure index…vvvvvvvvvv imp Normally more than 1
If less than 0.5….urgent refer Duplex………mild cases
Arteriography…….if ABI below 0.5
Describe the treatment approach for mild cases of brachial pressure index issues.
Conservative measures like stopping smoking, gradual exercise program, aspirin, and possibly surgical intervention for severe symptoms.
What are the indications for surgical intervention in brachial pressure index cases?
Rest pain, ischaemic ulceration, gangrene, or claudication symptoms limiting work or lifestyle.
How is the choice of surgical procedure determined in brachial pressure index cases?
It depends on the location and extent of the stenotic/occlusive disease, as well as the patient’s comorbidities.
Define the types of surgical procedures used in brachial pressure index cases.
Endovascular angioplasty or stenting, open surgical reconstruction, thromboendarterectomy for small segments, bypass graft for large segments, and amputation for gangrene.
What is the threshold for urgent referral in brachial pressure index cases?
An ankle brachial index (ABI) below 0.5.
What is the initial step in managing brachial pressure index issues?
Conservative measures like stopping smoking and implementing a gradual exercise program.
Describe the diagnostic steps for brachial pressure index issues.
Starting with duplex imaging for mild cases, followed by arteriography if ABI is below 0.5.
What are the considerations for choosing between endovascular angioplasty or open surgical reconstruction in brachial pressure index cases?
Anatomic location of the disease, its extent, and the patient’s comorbidities influence the choice.
How are small and large segments of stenotic/occlusive disease typically managed surgically in brachial pressure index cases?
Small segments may undergo thromboendarterectomy, while large segments may require bypass grafting.
Describe the management of gangrene in brachial pressure index cases.
Gangrene may necessitate amputation as a surgical intervention.
Describe the most common complication after bypass graft surgery.
Restenosis is the most common complication after bypass graft surgery.
Severity of the symptoms depends
mainly on the collaterls
What is the most common risk factor for peripheral artery disease (PAD)?
Diabetes mellitus is the most common risk factor for PAD.
Define microangiopathy and its role in causing PAD.
Microangiopathy is the mechanism by which diabetes mellitus causes PAD through small vessel thrombosis.
Limb ischemia + intact pulsations………..
small vessel thrombosis
Where is the most common site for an abdominal aortic aneurysm to occur?
The most common site for an abdominal aortic aneurysm is below the renal arteries.
What is the most common cause of abdominal aortic aneurysm?
Atherosclerosis is the most common cause of abdominal aortic aneurysm.
Describe the clinical picture of a ruptured abdominal aortic aneurysm.
The clinical picture of a ruptured abdominal aortic aneurysm includes severe abdominal pain referred to the back, hypotension, and the risk of rupture.
aaa emergency investigations
Inv……………us
TTT…….IMMEDIATE SURGERY if.
Indication of surgery with abdominal aneurysm (elective surgery):
Size………more than 5 cm Rapidly enlargement
Symptomatic
What is the most common symptom of an abdominal aortic aneurysm?
The most common symptom of an abdominal aortic aneurysm is pain.
What is the main cause of aortic aneurysm in young individuals?
Trauma is the main cause of aortic aneurysm in young individuals.
When is immediate surgery indicated for abdominal aneurysm?
When the size is more than 5 cm, rapidly enlarging, or symptomatic.
List the most common causes of severe abdominal pain referred to the back.
1- Perforated peptic ulcer
2- Acute cholecystitis
3- Acute pancreatitis
4- Aorta (rupture or dissection).
What is a V fistula?
It is a connection between an artery and a vein.
Describe the types of V fistula.
Congenital (local gigantism) and Acquired (due to trauma or surgery for dialysis).
What are the clinical presentations of V fistula?
Increased cardiac output, tachycardia, water hammer pulse. Compression of the fistula can lead to bradycardia.
How should congenital V fistulas be treated?
They do not require treatment.
How are acquired V fistulas managed?
They are managed with surgery.
Describe the most common cause of ulceration in diabetic foot.
Neuropathy is the most common cause of ulceration in diabetic foot.
What are the most common sites for ulceration in diabetic foot?
The heel and head of the 1st metatarsal are the most common sites for ulceration in diabetic foot, as they are pressure areas.
How can diabetic foot be prevented effectively?
The most effective way to prevent diabetic foot is through proper foot care.
What is the sequence of treatment in diabetic foot ulcer?
The sequence of treatment in diabetic foot ulcer involves debridement as the first step, followed by antibiotics and dressing.
What is the best investigation to exclude Marjolin ulcer or malignancy in a clear ulcer with clear discharge?
Biopsy is the best investigation to exclude Marjolin ulcer or malignancy in a clear ulcer with clear discharge.
If clear ulcer with clear discharge……..
.just dressing
Most imp inv to exclude osteomyletitis…..
If gangrene…….
Most imp inv to exclude osteomyletitis…..MRI followed by x-ray If gangrene…….amputation
What is the most important investigation to exclude osteomyelitis in diabetic foot?
MRI is the most important investigation to exclude osteomyelitis in diabetic foot.
What is the recommended treatment if gangrene is present in diabetic foot due to Buerger disease in a young male smoker?
Amputation is recommended if gangrene is present in diabetic foot due to Buerger disease in a young male smoker, as it is caused by neurovascular inflammation and presents with recurrent claudicating.
Buerger disease
Young male smoker
Cause…….
Cp……..
TT
Buerger disease
Young male smoker Cause…….neurovascular inflammation Cp……..recurrent claudicating
Superficial thrombophlebitis Raynauds phenomenon
TTT…….stop smoking, sympathectomy, and amputation with severe cases
Describe superficial thrombophlebitis.
Veins become red, tender, and cord-like with associated fever.
What is Raynaud’s phenomenon?
A condition where blood vessels in the fingers and toes constrict in response to cold or stress, causing numbness and color changes.
What are the indications for carotid artery surgery?
Best for carotid stenosis ≥70% in asymptomatic patients and
>50% in symptomatic patients.
What are the contraindications for carotid artery surgery?
Severe neurologic deficit post-cerebral infarction, occluded carotid artery, and concurrent illnesses limiting life expectancy.
How is superficial thrombophlebitis treated?
Treatment includes compression by Veins become red, tender, and cord like Fever
If recurrent….suspect visceral cancer Risk………DVT
Prophylaxis against DVT…………LMWH….vvvvvvvvvvvvvvvv imp
TTT……… compression by elastic stoking…vvvvvvv imp
Define LMWH in the context of DVT prophylaxis.
LMWH stands for Low Molecular Weight Heparin, a common prophylactic treatment for deep vein thrombosis.
What is the treatment of choice for carotid stenosis?
TTT of choice of carotid stenosis is end arterectomy NOT stent ….vvvvvvvvvv imp.
Describe the risk associated with DVT.
Deep vein thrombosis poses a risk of developing pulmonary embolism if left untreated.
What should be suspected if superficial thrombophlebitis recurs?
Visceral cancer should be suspected if superficial thrombophlebitis recurs.
How is DVT managed?
Management includes LMWH prophylaxis and compression by elastic stockings.
Describe Deep Vein Thrombosis (DVT).
DVT is a condition where blood clots form in the deep veins of the body, commonly in the legs.
Explain the Virchow triad in relation to DVT.
Predisposing factors:
Virchow triad:
The Virchow triad consists of three factors that contribute to the formation of blood clots: damage to the vessel lining, venous stasis, and hypercoagulability.
What are some predisposing factors for DVT?
Predisposing factors for DVT include damage to vessel lining, venous stasis (prolonged immobility), hypercoagulability (e.g., antithrombin 3 deficiency, protein C and S deficiency), malignancy, oral contraceptive use, and obesity.
What are some common clinical symptoms of DVT?
Common clinical symptoms of DVT include pain, swelling, and tenderness in the affected area.
How is DVT diagnosed?
DVT is often diagnosed using duplex ultrasound, which allows visualization of blood flow and clots in the veins.
DVT Treatment
Treatment:
LMWH…….immediately
Warfarin
Duration…….at least 3- 6 months……..vvvvvvvvv imp Target……..INR 2-3
Describe the treatment for a patient with a high INR and no bleeding while on warfarin
Stop warfarin, administer vitamin K1
What is the immediate treatment for a patient on warfarin with life-threatening bleeding like intracranial or gastrointestinal hemorrhage?
Hospital management, vitamin K1 IV, Fresh frozen plasma
How should a patient with an INR above 9 and no bleeding be managed while on warfarin?
Stop warfarin, administer vitamin K1
Define LMWH in the context of treatment mentioned
Low Molecular Weight Heparin
What should be done for a patient with an INR of 5-8 and no bleeding while on warfarin?
Stop warfarin
INR 4.5-5……….
INR 4.5-5……….switch one dose
Do you increase or decrease the dose for a patient with an INR of 3-4.5 while on warfarin?
Decrease dose
How long should a patient be on warfarin treatment after a high INR episode?
At least 3 months
What is the target INR level for a patient on warfarin treatment?
INR 2
Describe the management for a low INR in a patient on warfarin
Consider increasing the dose temporarily
Describe the protocol for warfarin use in elective surgery.
Warfarin is typically withheld for 5 days before elective surgery.
What is the recommended approach for warfarin use in emergency surgery?
In emergency surgery, infusions of fresh-frozen plasma are often used.
How is bridging therapy managed in patients on warfarin?
When bridging therapy is needed, Low Molecular Weight Heparin (LMWH) is usually used.
Define bridge therapy in the context of anticoagulation.
Bridge therapy is used in patients who require temporary interruption of anticoagulation therapy.
Do patients with atrial fibrillation (AF), artificial valves, or recent thromboembolism need bridge therapy?
Yes, patients with AF, artificial valves, or recent thromboembolism may require bridge therapy.
Describe the timing for stopping and restarting heparin in bridge therapy.
Before surgery, stop the heparin 24 hours prior, and after surgery, wait at least 24 hours before restarting.
What type of heparin is typically used in bridge therapy?
Low Molecular Weight Heparin (LMWH) is commonly used.
How soon after surgery should anticoagulation therapy be restarted?
Anticoagulation therapy should usually be restarted on the day after surgery.
When should aspirin be stopped before elective surgery?
5 days
What should be done if a patient on aspirin needs emergency surgery?
Stop aspirin now and give platelets
Describe when NSAIDs should be stopped before operations.
5 days before surgery
Differentiate between unfractionated heparin and LMWH in terms of administration and monitoring.
Unfractionated heparin is given via IV route, causes more complications, and needs monitoring; LMWH does not need monitoring and can be given at home
What are the distinguishing features of cellulitis, DVT, and hematoma in terms of swelling, pain, tenderness, and fever?
Cellulitis: high-grade fever; DVT: low-grade fever, past history of DVT; Hematoma: patient on warfarin, high INR
Explain the cause and clinical manifestations of heparin-induced thrombocytopenia.
Antibodies activating platelets cause arterial or venous thrombosis, along with thrombocytopenia
What is the treatment for heparin-induced thrombocytopenia?
Stop heparin, consider plasmapheresis, and never give platelets as it worsens the condition
Describe the timing of thrombosis induced by warfarin.
Thrombosis can occur 4 days after starting warfarin, with a maximum of 3 days.
What is the most common affected organ by warfarin-induced thrombosis?
The skin, with the thigh, breast, and abdomen being common sites.
What is the recommended treatment for warfarin-induced thrombosis?
Stop warfarin and administer vitamin K, along with Low Molecular Weight Heparin (LMWH).
List the types of ulcerations.
Venous ulcer, Ischemic ulcer, Neuropathic ulcer.
Where is the most common site for ischemic ulcers?
The tip of the fingers.
Where is the most common site for neuropathic ulcers?
Pressure sites.
Where is the most common site for venous ulcers?
Against the medial malleolus.
Is ischemic ulcer painful?
Yes.
Are neuropathic ulcers painful?
Yes, neuropathic ulcers can be painful.
Are venous ulcers painful?
Yes, venous ulcers can be painful.
What is the main treatment for venous ulcers?
Compression stockings and elevation of the leg are main treatments for venous ulcers.
Are antibiotics being used for venous ulcer??.
no
What is important in preventing complications in the foot of a diabetic patient?
Proper foot care and good glycemic control are crucial in preventing complications in the foot of a diabetic patient.
