Vascular/Trauma Flashcards
How long to TIA’s last?
24 hrs or less
Risk of stroke in first 48 hrs of TIA?
4-10%
Risk of pseudoanuerysm after endovascular access? Sx’s
0.5-8%
Presents with pain at access site and pulsatile mass.
Confirm with arterial duplex
Treatment for pseudoanerysm after endovascular access?
Try ultrasound compression for 10-30 minutes
Direct thrombin injection
However if large (>5cm) and overlying skin compromise then patient needs immediate surgical repair.
Treatment for claudication?
Risk factors for cardiac mortality much higher than limb loss, thus start:
- High dose statin
- ASA vs plavix vs Cilostrazol
- Smoking sessation
- Exercise training
Revascularize only for sever disease or medical therapy has failed
MOA of cilotrazol?
PDE3 inhibitor which decreases PKA which inhibits platelet aggregation
- also decreasing PKA leads to vasodilation
Median sternotomy is needed for access to which arteries?
Ascending aorta Aortic arch Innominate artery Right subclavian Left common carotid
What is infra/supraclavicular incisions give you access too? Arteries that is.
axillary and subclavian arteries
What is the incision for access to left subclavian artery?
3rd interspace anterior thoracotomy
Leriche triad?
Buttock claudication
Abscess femoral pulses
Impotence
- lesions at aortic bifra an aorto-bifemoral bypass
- presents in younger people than infrainguinal disease
Treatment for popliteal aneurysms?
If greater than 2cm needs bypass WITH ligation
Marfan’s syndrome mutation?
Fibrillin gene or FBN1
What is indication to fix facial nerve injury in trauma?
If the lac is lateral to the lateral canthus of eye.
Facial nerve has arborization when medial to this.
- Otherwise needs surgical exploration
Tx for facial nerve injury lateral to lateral canthus of eye?
approximate epineural layers
landmark for distal panc vs whipple for pancreatic trauma?
SMV.
to Right of SMV suggest whipple or debridement of head and place drains. Delayed whipple
Most common complication of pancreatic injury?
Fistula
- Drain amylase 3x serum
- typically <200cc/day–> take 2 weeks to treat
Tx for fistula after panc trauma?
NPO
TPN
Octreotide
Conservative management
Findings of pancreatic trauma on CT?
HYPOattenuation
What causes trauma to central tendon of diaphragm?
Blunt trauma, penetrating can happen anywhere
GCS based on worst or best score?
Best
what is the Mattox maneuver and what is it used for? AKA?
“left medial visceral rotation” Medialize the left lateral organs.
Spleen, left colon, tail of pancreas, fundus of stomach and left kidney are all moved midline.
-needed for supramesocolic active hemorrhage. Get supraceliac exposure . You can divide left crus if needed to get into chest cavity.
Main steps of Mattox maneuver?
incise white line of told. Sharply incise spleno-diaphragmatic attachments and then bluntly dissect organs away from posterior abdominal muscles
Distal ureteral injuries need?
Reinplantation of ureter into bladder.
- two layer absorbable sutures
How do middle ureter transections get repaired?
Transureteroureterostomy
What can you do if you have a large bladder defect in trauma, repair?
Vesicopsoas hitch. Attach bladder after dividing umbilical arteries and sometimes superior vesicular artery to central tendon of psoas muscle.
How many zones of retroperitoneal hemorrhage?
3
What is zone 1 of retroperitoneal hemorrhage?
Divided into supramesocolic or inframesocolic
- Central and all major vasculature aortor and IVC and its major proximal branches
What is zone 2 of retroperitoneal hemorrhage?
More lateral but central
What is zone 3 of retroperitoneal hemorrhage?
Pelvis
3 phases of cardiac tamponade?
1- CO maintained by autoregulation, tachycardia/SBP. Diastolic filling compromised
- CO compromised
- Severe CO compromise with paricardial pressure higher than ventricular filling pressure
Landsmarks for subclavian central line access?
Sternal notch
medial third of clavicle
Deltopectoral groove
hard signs for OR with neck injury?
- Hemodynamically unstable
- Tracheal injury (subcue air)
- Vascular injury ( pulsatile hematoma, expanding hematoma, bruit or thrill)
Zone 1 of anterior neck?
Means anterior to anterior boarder of SCM
- clavicle to cricoid
Zone 2 of anterior neck?
Cricoid to mandible
Zone 3 of anterior neck?
Mandible to base of skull
Rule out neck vessel injury?
CTA 4 vessel angiography
Doppler with color
Posterior triangle of neck?
Post SCM
Trap
Clavicle
How is nitrous oxide made?
converts L-arginine to L-citrulline by nitrous oxide synthase
How long for dual antiplatelet for DES?
6 months sometimes 12 before holding for 5-7 days before a surgery
Most likely to get perfused from Type B aortic dissection?
Left Renal
- important consideration prior to fixing
Woo is at highest risk for PE?
Surgical patient= 25%
- Malignancy is only about 11%
Order of preferred AV fistula?
- Auto Radiocephalic
- Auto brachio-cephalic
- Transposed brachial-basilic
- Upper arm brachial-cephalic PTFE graft
Why should a brachial basilic AVF be transposed?
Proximity to medial cutaneous nerve
- supplies proximal to elbow and medial side
Carotid body tumors derived from?
Ectoderm- Neural crest cells
Treatment for asymptomatic fibromusclar dysplasia of carotid?
Antiplatelet therapy
Symptomatic fibromuscular dysplasia of carotid tx?
Angioplasty
Order of most common thoracic outlet syndromes?
- Nerve compression
- Venous clot
- Arterial clot
Difference between suppurative thrombophlebitis and superficial venous thrombophlebitis?
Suppurative has systemic symptoms of fevers, chills, pus express from IV site, tenderness to palpation of cord like structure.
Superficial only has redness but no pain, no need for iv abx or blood cultures. Just remove IV
Most common bacteria of thrombophlebitis? How about central line infections?
Staph A, gram neg and poly microbes
Central lines if staph epi
Triad for hemobilia?
Abdominal pain
Jaundice
GI bleed
Causes of thoracic outlet syndrome?
Hypertrophy, Cervical ribs, Aneurysms, and lung tumors
Adsons test?
30 degrees abducted, fully extended elbow. feel radial pulse
- then have patient extend neck and turn it to symptomatic side then take and deep breath and hold it
- positive test is diminished or absent radial pulse
Acute limb ischemia from thrombus who presents in under 2 weeks is best treated with?
Catheter directed thrombolysis
- if greater than 2 weeks then thromboembolectomy is needed or bypass
Post thrombolic syndrome symptoms?
Edema Venous stasis Incompetent valves Varicose veins pain ulcers pigmentation calf muscle disfunction
Flow velocities concern for renal artery stenosis?
180-200cc/s
- or ratio of this to aorta of >3.5
What is a type 4 endoleak?
Fenestration in graft–> from needle holes. Resolves in 24 hrs. Type V is from unknown but continues to leak
Classifications of acute limb ischemia?
I, IIa, IIb and III
What is Rutherford acute limb ischemia class I?
Viable non immediately threatened limb No sensory loss No motor loss Audible Artery Audibile vein
What is Rutherford acute limb ischemia class IIa?
Salvageable if promptly treated. Minimal sensory loss- toes
No muscle weakness
Non audible artery
Audible veins
What is Rutherford acute limb ischemia class IIb?
Salvageable limb Sensory loss more than toes Mild to moderate muscle weakness No Audible Artery Audibile vein
What is Rutherford acute limb ischemia class III?
Major tissue loss with permanent nerve damage Profound anesthesia Paralysis No Audible Artery No Audibile vein
How many classes of PVD Rutherford? What are they
6-(0-5) 0- Asymptomatic 1. Claudication (M-M-S) 2. Rest pain 3. Ischemic ulcer 4. Severe ischemic ulcer with gangrene
