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VASCULAR/HAEM Flashcards

1
Q

What are some causes of AAA?

A
  • atheroma
  • trauma
  • infection
  • CTDs
  • inflammation e.g. Takayasu’s
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2
Q

What screening is in place for AAA? Explain the results

A

Offered as one off to all men over 65 - USS

  1. SMALL (3-4.4cm)
    - no treatment, annual check-up + lifestyle advice
  2. MEDIUM (4.5 - 5.4cm)
    - no treatment, 3-monthly check up, lifestyle advice
  3. HIGH (5.5cm or greater)
    - high risk of bursting = elective EVAR required
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3
Q

How do you manage a ruptured AAA?

A

If haemodynamically stable, use CT to diagnose rupture

  1. Inform vascular surgeon + anaesthetist
  2. Perform: ECG, FBC, Amylase, Crossmatch, catheterise
  3. IV access - 2 large bore cannulae
  4. Treat shock with O- blood
    - keep sBP below 100 to avoid rupturing contained leak
  5. Give prophylactic Abx - cefuroxime + metronidazole
  6. Immediate transfer to theatre from A+E
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4
Q

What are some causes of microcytic anaemia? (TAILS)

A 
T - Thalassaemia
A - Anaemia of chronic disease
I - Iron deficiency anaemia (= chronic blood loss, malabsorption, poor intake)
L - Lead poisoning
S - Sideroblastic anaemia
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5
Q

What are some causes of normocytic anaemia?

A 
A - Acute blood loss
A - Anaemia of chronic disease
A - Aplastic anaemia
H - Haemolytic anaemia
H - Hypothyroidism
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6
Q

What are (i) megaloblastic + (ii) normoblastic causes of macrocytic anaemia?

A

(i) B12 or folate deficiency
(ii) alcohol excess
- reticulocytosis
- hypothyroidism
- liver disease
- drugs (azathioprine, phenytoin)
- marrow infiltration
- myelodysplastic syndromes

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7
Q

What do iron studies show in IDA?

A 
FERRITIN
- low, if normal then there may be an inflammatory process going on at same time
TIBC
- increased
TRANSFERRIN SATURATION
- increased
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8
Q

What is the 2ww pathway for patients with IDA?

A

All aged over 60 with IDA

Aged over 50 with rectal bleeding + IDA

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9
Q

If there is both B12 + folate deficiency, how do you treat?

A

Treat B12 FIRST

- treating pts with folic acid when they have B12 deficiency can lead to subacute combined degeneration of the cord

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10
Q

What test is specific for pernicious anaemia?

A

Intrinsic factor antibody

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11
Q

How is B12 deficiency treated?

A

1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months

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12
Q

What are the inherited causes of haemolytic anaemia?

A
  • Hereditary spherocytosis
  • Hereditary elliptocytosis
  • Thalassaemia
  • Sickle cell anaemia
  • G6PD
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13
Q

What are the acquired causes of haemolytic anaemia?

A

AIHA

  • alloimmune haemolytic anaemia
  • paroxysmal nocturnal haemoglobinuria
  • microangiopathic haemolytis anaemia
  • prosthetic heart valve related haemolysis
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14
Q

How does hereditary spherocytosis tend to present?

A

Jaundice, gallstones, splenomegaly

- aplastic crisis in presence of parovirus

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15
Q

How is hereditary spherocytosis managed?

A

Folate supplementation + splenectomy

- cholecystectomy may be required

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16
Q

How does G6PD tend to present? What are some triggers?

A

Jaundice, gallstones, anaemia, splenomegaly

  • Heinz bodies on blood film
  • triggers = broad beans, anti-malarials, sulfalazine
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17
Q

How is AIHA managed?

A
  1. Blood transfusions
  2. Prednisolone
  3. Rituximab
  4. Splenectomy
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18
Q

How do you confirm diagnosis of sickle cell disease?

A

Hb electrophoresis

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19
Q

What are some complications of sickle cell disease?

A
  • anaemia
  • increased risk of infection
  • stroke, AVN in large joints
  • pulmonary HTN
  • priapism (painful + persistent erection)
  • CKD
  • sickle cell crisis
  • acute chest syndrome
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20
Q

What is the general management for sickle cell patients?

A
  1. Avoid dehydration, keep warm + other triggers
  2. Vaccines up to date
  3. Abx prophylaxis = phenoxymethylpenicillin
  4. Hydroxycarbamide
  5. Blood transfusions for severe anaemia
  6. Bone marrow transplant can be curative
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21
Q

Describe thrombotic/vaso-occlusive sickle crisis.

A

Painful crisis

  • precipitated by infection, dehydration, deoxygenation
  • RBCs clog capillaries causing distal ischaemia
  • can cause priapism in men
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22
Q

Describe splenic sequestration crisis in sickle cell.

A

RBCs block flow to spleen

  • large + painful spleen
  • medical emergency use blood transfusions + fluid resus
  • splenectomy is definitive treatment
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23
Q

Describe aplastic crisis in sickle cell.

A

Caused by parovirus B19

- sudden drop in Hb as temp loss of creation of new RBCs

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24
Q

Describe acute chest syndrome in sickle cell.

A

Presents with dyspnoea, chest pain, pulmonary infiltrates on CXR, low pO2
- medical emergency

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25
Q

How is beta-thalassaemia managed?

A
  1. Regular transfusions
    - monitor serum ferritin levels
  2. Iron chelation - prevent/treat iron overload
  3. Splenectomy
  4. Bone marrow transplant can potentially be curative
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26
Q

What are some differentials for abnormal/prolonged bleeding?

A
  • thrombocytopenia (low platelets)
  • haemophilia A or B
  • von Willebrand disease
  • DIC (usually 2ndary to sepsis)
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27
Q

What will a platelet count of less than 50 cause?

A
  • spontaneous bruising + prolonged bleeding times

- nosebleeds, bleeding gums, heavy periods, easy bruising, blood in urine/stool

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28
Q

What are those with a platelet count of less than 10 at risk of?

A

SPONTANEOUS BLEEDING

  • intracranial bleeds or GI bleeds
  • require platelet transfusion
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29
Q

How do you manage ITP?

A

CONSERVATIVE

  1. Prednisolone
  2. IVIG
  3. Rituximab
  4. Splenectomy
  • monitor platelet count + educate pt re concerning signs of bleeding
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30
Q

How do you diagnose heparin induced thrombocytopenia?

A

Test for HIT antibodies in blood

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31
Q

What investigations diagnose von Willebrand Disease?

A
  1. Prolonged bleeding time
  2. APTT may be prolonged
  3. Factor VIII levels may be moderately reduced
  4. Normal platelets
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32
Q

How is von Willebrand disease managed?

A

Does not require day-to-day treatment
In response to major bleeding/trauma/pre-op:
1. Desmopressin - stimulate release of vWF
2. Infuse vWF
3. Factor VIII infusion

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33
Q

How is thrombophilia diagnosed?

A

PROLONGED APTT

- bleeding time, thrombin time, prothrombin time are all normal

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34
Q

How do you manage thrombophilia?

A
  1. Replace factor 8 or 9 by IVI
  2. For ACUTE episodes:
    - infusions of clotting factors or FFP
    - desmopressin to stimulate release of vWF
    - tranexamic acid
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35
Q

What are some causes of DIC?

A
  • sepsis
  • trauma
  • obstetric complications e.g. amniotic fluid embolism or HELLP syndrome
  • malignancy
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36
Q

How do you investigate + diagnose DIC?

A
  1. Low platelets
  2. Prolonged APTT, PT and bleeding time
  3. Fibrin degradation products are often raised
    schistocytes due to microangiopathic haemolytic anaemia
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37
Q

How do you manage DIC?

A

Find + address underlying cause

  1. RESUS
    - A+B: consider airway support + O2
    - C: IV access, consider fluids, blood, platelets + FFP
    - discuss with ICU
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38
Q

What are some risk factors for PAD?

A
  • older age
  • FHx
  • male
  • smoking + alcohol
  • poor diet
  • minimal exercise
  • obesity
  • diabetes
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39
Q

What is Leriche’s syndrome?

A 
Occlusion in distal aorta or common iliac artery.
Triad of:
1. Thigh/buttock claudication
2. Absent femoral pulses
3. Male impotence
40
Q

What are the 6 P’s of critical limb ischaemia?

A
  1. Pallor
  2. Pulseless
  3. Perishingly cold
  4. Paraesthesias
  5. Pain
  6. Paralysis
41
Q

What investigations should be performed in PAD?

A
  1. ABPI
    - over 0.9 = normal
    - 0.6 to 0.9 = mild
    - 0.3 to 0.6 = moderate-severe
    - Less than 0.3 = severe, leading to critical limb ischaemia
  2. Arterial doppler USS
  3. Angiography (CT/MRI)
  4. R/O: DM, arthritis (CRP/ESR), anaemia, renal disease, dyslipidaemia, cardiac ischaemia (ECG), thrombophilia
42
Q

What management for PAD can be done to help manage risk factors?

A

1 QUIT smoking

  1. Treat HTN + high cholesterol
  2. Supervised exercise programmes
43
Q

What medical/surgical interventions can be used in PAD?

A 
MEDICATIONS:
- Atorvastatin 80mg
- Clopidogrel 47mg
- Naftidrofuryl oxalate (peripheral vasodilator)
SURGICAL:
- percutaneous transluminal angioplasty
- surgical reconstruction
- amputation
44
Q

What is the difference between wet + dry gangrene?

A 
WET = tissue death AND infection
DRY = death but no infection
45
Q

How is wet gangrene managed?

A

Analgesia
broad spec Abx
Surgical debridement
Amputation

46
Q

How is dry gangrene managed?

A

Manage with restoration of blood supply + amputation

47
Q

What are the clinical features of necrotizing fasciitis?

A

ACUTE

  • painful, erythematous lesions develop
  • often worsening cellulitis with pain out of keeping with physical features
  • extremely tender over infected tissue
48
Q

How do you manage necrotizing fasciitis?

A
  1. Urgent surgical debridement

2. IV Abx

49
Q

How do you manage cellulitis?

A 
MILD-MODERATE:
- flucloxacillin
- clarithromycin if pregnant 
- doxycycline if penicillin allergic
SEVERE:
- co-amoxiclav, cefuroxime, clindamycin or ceftriaxone
50
Q

What investigations are performed in suspected chronic venous insufficiency?

A
  1. Duplex USS - venous reflux
  2. Ascending phlebography
  3. CT/MR venography
  4. CT abdo/pelvis - r/o masses compressing iliac vein
51
Q

How is chronic venous insufficiency managed?

A
  1. Grading compression stocking
    - emollient can be added to combat eczematous changes
  2. Endovenous ablation or saphenectomy = surgical stripping
  3. Injection sclerotherapy
52
Q

What examinations/tests should be done to diagnose varicose veins?

A
  1. INSPECTION - start with pt standing
    - ulcers, venous eczema, haemosiderin
    - palpate veins for tenderness (phlebitis) or hardness (thrombosis)
    - if ulcers present, palpate pulses to R/O PAD
  2. COUGH IMPULSE at sapheno-femoral junction - indicates incompetence of valve
  3. AUSCULTATE over varicosities for bruits (indicate AV malformation)
  4. Examine abdomen, pelvis in F + external genitalia in M
  5. Doppler USS
53
Q

How are varicose veins managed?

A
  1. Treat any underlying cause
  2. Education:
    - avoid prolonged standing, elevate legs where possible
    - support stockings
    - lose weight, regular walks
  3. Endovascular treatment
    - radiofrequency ablation
    - endovenous laser ablation
    - injection sclerotherapy
  4. Surgery
    - saphenofemoral ligation
    - stripping from groin to upper calf
54
Q

Name some risk factors for VTE. As many as possible.

A

GENERAL
- increasing age, obesity, FHx, pregnancy, immobility, hospitalisation, anaesthesia
UNDERLYING CONDITIONS
- malignancy, thrombophilia, Factor V Leiden, HF, antiphospholipid, Bechet’s, polycythaemia, nephrotic syndrome, sickle cell, PNH, hyperviscocity syndrome, homocystinuria
MEDICATIONS
- COCP, HRT, tamoxifen, raloxifene, antipsychotics especially olanzapine

55
Q

What amount of calf swelling is significant for a DVT? How is it measured?

A

More than 3cm difference between legs

- circumference of calf 10cm below tibial tuberosity

56
Q

What number of Well’s score indicates DVT is likely?

57
Q

If you have intermediate suspicion of VTE, how do you manage in terms of anticoagulation?

A

Commence if the results of the diagnostic tests are expected to be delayed 4 hours or more

58
Q

What further tests/management should be done in patients with an unprovoked DVT/PE who are NOT known to have cancer?

A
  • Physical exam
  • CXR
  • bloods = FBC, Ca, LFTs
  • urinalysis
  • thrombophilia screening = antiphospholipid antibodies (anti-cardiolipin) + hereditary thrombophilia testing if unprovoked DVT/PE in 1st degree relative.
59
Q

What advice should you give to patients post PE/DVT?

A
  • Engage in regular exercise/walking once discharged
  • Elevate affected leg when sitting
  • Extended travel OR travel by plane should be delayed for at least 2 weeks after starting anticoagulants
60
Q

What % of carotid artery stenosis is indicative for carotid artery endarterectomy?

A

More than 70%

61
Q

When do you get schistocytes on blood film?

A

Fragments of RBCs - indicates trauma to RBCs

- can be present in HUS, DIC, TTP, metallic heart valves + haemolytic anaemia

62
Q

When do you get smudge cells on blood film?

A

Ruptured WBCs which can indicate CLL

63
Q

When do you get sideroblasts on blood film?

A

Immature RBCs which occur when bone marrow is unable to incorporate iron into Hb molecules - can indicate myelodysplastic syndrome

64
Q

What will iron studies show in IDA?

A

Low or normal ferritin
High TIBC
High transferrin saturation

65
Q

What are the side effects of EPO injections?

A

Flu-like symptoms, hypertension, rise in platelets + risk of VTE

66
Q

What medications can cause folate deficiency?

A

anti-epileptics e.g. phenytoin, valproate
methotrexate
trimethoprim

67
Q

What is pernicious anaemia?

A

Autoimmune condition where antibodies form against parietal cells or intrinsic factors
- preventing absorption of vitamin B12

68
Q

How do you manage hereditary spherocytosis?

A

Presents with jaundice, gallstones, splenomegaly + aplastic crisis in presence of parovirus

  • raised MCHC
  • raised reticulocytes
  • spherocytes on blood film
69
Q

How do you treat hereditary spherocytosis?

A
  1. Folate supplementation + splenectomy

2. Cholecystectomy may be required

70
Q

How do you manage sickle cell disease?

A
  1. Avoid dehydration + other triggers of crises
  2. Ensure vaccines up to date
  3. Abx prophylaxis = penV
  4. Hydroxycarbamide - stimulate foetal Hb (does not lead to sickling of RBCs)
  5. Blood transfusions if severe anaemia
  6. Bone marrow transplant can be curative
71
Q

How do you manage iron overload in thalassaemias?

A

Limiting transfusions + iron chelation (desferroximine)

72
Q

If pts are not bleeding, at what platelet count do they require a tranfusion?

A

Below 10 - at risk of spontaneous bleeds

73
Q

How do you manage immune thrombocytic purpura?

A
  • prednisolone
  • IVIG
  • rituximab
  • splenectomy
74
Q

How is heparin induced thrombocytopenia diagnosed + managed?

A

Test for HIT anotbodies in blood

Manage by stopping heparin + using alternative anticoagulant

75
Q

How do you diagnose von Willebrand disease?

A

Based on hx, FHx and

  • prolonged bleeding time (PT)
  • APTT may be prolonged
  • factor VIII may be slightly reduced
76
Q

How do you manage vWD?

A

does NOT require any day-to-day treatment
Management in response to major bleeding/trauma/in preparation for ops:
1. Desmopressin to stimulate release of vWF
2. vWF infusion
3. Factor VIII infusion along with plasma derived vWF

77
Q

What will the coagulation profile show in haemophilia?

A

Prolonged APTT

- bleeding time, thrombin time + prothrombin time all normal

78
Q

What are some causes of DIC?

A
  • sepsis
  • trauma
  • obstetric complications e.g. aminiotic fluid embolism or hemolysis, elevated liver function tests, and low platelets (HELLP syndrome)
  • malignancy
79
Q

What investigations are done in DIC + what do they show?

A
  • low platelets
  • prolonged APTT, prothrombin and bleeding time
  • fibrin degradation products are often raised
  • schistocytes due to microangiopathic haemolytic anaemia
80
Q

What investigations should you perform in suspected leukaemia?

A
  1. FBC - take within 48h if suspected leukaemia
  2. Blood film
  3. LDH - often raised
  4. Bone marrow biopsy = gold standard
  5. CXR
  6. Lymph node niopsy
  7. LP (?CNS involvement)
  8. CT/MRI/PET
81
Q

WHat are your DDx for petechiae?

A
  • NAI
  • leukaemia
  • meningococcal septicaemia
  • vasculitis
  • HSP
  • ITP
82
Q

WHat is seen on blood film in ALL + AML?

A

Blast cells

83
Q

WHy in ALL is there is a risk of infection, anaemia + bruising?

A

Cancerous cells fill the bone marrow so healthy RBCs + platelets cannot be made

84
Q

What conditions is AML associated with? Who is at greater risk of developing?

A

Associated with MDS + aplastic anaemia

- children with Down’s + Li-Fraumeni syndrome

85
Q

What investigations are performed in suspected Hodgkin’s Lymphoma? What do they show?

A
  1. Bloods - FBC, film, ESR, LFT, LDH, urate, Ca
  2. LDH - raised
  3. Lymph node biopsy
    - Reed-Sternberg cells
  4. CT/MRI/PET
86
Q

Name 3 examples of non-Hodgkins lymphomas?

A
  1. Burkitt = associated with RBV, malaria + HIV
  2. MALT = mucosa-associated lymphoid tissue = usually around stomach + associated with H. pylori
  3. Diffuse large B cell = rapidly growing painless mass in over 65s
87
Q

What are the tests you perform in suspected myeloma?

A
  1. FBC - low WCC
  2. Ca - raised
  3. ESR - raised
  4. Plasma viscosity - raised

Then serum + urine electrophoresis
- bone marrow biopsy to confirm diagnosis

88
Q

What imaging would you perform in myeloma to assess for bone lesions?

A
  1. Whole body MRI
  2. Whole body CT
  3. Skeletal survey by x-ray
89
Q

What mutation is present in polycythaemia rubra vera?

90
Q

What are the symptoms + signs of polycythaemia rubra vera?

A

often asymptomatic

  • hyperviscosity = headaches, dizzy, tinnitus, visual disturbance
  • itchy after hot bath + burning in finger and toes
  • facial plethora
  • splenomegaly
  • gout
  • features of arterial or venous thrombosis
91
Q

What investigations are performed in polycythaemia rubra vera?

A
  1. FBC - raised RCC, Hb, HCT, PCV (raised WCC + platelets)
  2. B12 - raised
  3. Marrow - hypercellularity with erythroid hyperplasia
  4. Reduced serum EPO
  5. Raised red cell mass on Cr studies + splenomegaly in setting of normal PaO2 is diagnostic
92
Q

How do you treat polycythaemia rubra vera?

A

Aim to keep HCT below 0.45

  1. Hydroxycarbamide if high risk
  2. Venesection if low risk
  3. Aspirin 74mg OD
93
Q

In what condition do you get teardrop RBCs?

A

myelofibrosis

94
Q

What are some inherited causes of thrombophilia?

A

Factor V Leiden
Prothrombin gene mutation
Protein C+S deficiency
Antithrombin deficiency

95
Q

What are some acquired causes of thrombophilia?

A

COCP

Anti-phospholipid syndrome

FINALS (14 decks)

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