18. AAA lectures

Question 1

What are the main early signs that someone has significant blood loss

Answer 1

clinical shock so high HR low BP

Question 2

When stopping a catastrophic bleed and someone is on warfarin for example, how do you reverse the action of the warfarin

Answer 2

with PCC - prothrombin complex concentrate

Question 3

what anti-fibronoltyic agent helps to stabilise blood clotting and should be given within the first hour of haemorrhage occurring

Answer 3

tranexamic acid

Question 4

when ordering blood which blood type would you use;
a) in an extreme emergency
b) if you can wait about 15 minutes from the sample arriving in the lab
C) the safest product if time allows (around 45-60mins)

Answer 4

a) group O RhD negative
b) group specific (ABO and RhD compatible)
c) crossmatched (fully screened for antibodies)

Question 5

What are the components of pack 1 of the major haemorrhage pack

Answer 5

4 units of red cells

4 units of fresh frozen plasma (FFP)

Question 6

what are the components of pack 2 of the major haemorrhage pack if the bleeding continues

Answer 6

4 units of red cells
4 units of FFP
1 dose platelets
2 packs of cryoprecipitate

Question 7

once the haemorrhage is under control, what is the patient at risk of

Answer 7

thrombosis and so they will eventually need thromboprophylaxis

Question 8

when you generally look at the patient in a vascular examination what things do you comment on (in notes you’ll see it abbreviated to An/J/Cy/Cl

Answer 8

no anaemia, jaundice, cyanosis and clubbing

Question 9

if someones femoral pulse is rock hard what does this suggest

Answer 9

calcification

Question 10

Again what are the 6 Ps in critical limb ischemia

Answer 10

pale
perishing cold
pulseless
painful

parenthetic
paralysed

Question 11

in critical skin Ischaemia which are the most worrying signs (which of the 6ps)

Answer 11

Paraesthetic (muscle tenderness)

paralysed (numb mottled)

Question 12

in chronic ischemia what does the Fontaine classifications I-IV mean

Answer 12

I - asymptomatic
II- claudication
III- rest pain
IV- tissue loss

Question 13

what is claudication

Answer 13

aching muscles on effort
predictable
worse on hills, with loads, at speed
settles swiftly with rest

Question 14

what are the main treatment options for peripheral vascular disease

Answer 14

• Stop smoking
• Antiplatelet therapy (aspirin 75mg od)
• Blood pressure control (sBP less than 140)
• Cholesterol reduction
• Regular exercise
• Weight loss
• Controlled diabetes

Question 15

In cerebrovascular disease what are the main issues.

Answer 15

atheroma in the carotid artery
can lead to stroke, TIA (stroke symptoms the recover within 24 hours), amaurosis (transient blindness in ipsilateral eye)

Question 16

what are the investigations for cerebrovascular disease

Answer 16

Carotid duplex scan or angiography

Question 17

what are the indications for a carotid endarterectomy

Answer 17

symptomatic patients within the past 6 months of symptoms
arterial disease greater than 70%. stenosis of the ICA
must be fit for surgery and have at least a 2 year life expectancy

Question 18

What is the difference between abnormal dilation of an artery and ectasia

Answer 18

abnormal dilation of an artery is greater than 50% of its diameter
ectasia is dilation of up to 50%

Question 19

what is arteriomegaly

Answer 19

generalise dilation of the arteries

Question 20

what is the main aetiology of aneurysm

Answer 20

Atherosclerotic meaning you get it with age
mycotic meaning you get it from an infection of the arterial wall
connective tissue disorder such as marfans or Ehlers-Danlos syndromes (EDS)

Question 21

the shape of an aneurysm can be described as fusiform or saccular, what is the difference

Answer 21

saccular means asymmetrical dilatation whereas fusiform is symmetrical

Question 22

fill out the normal transverse diameter sizes for the following;

a) a normal aorta
b) ectasia
c) small AAA
d) large AAA

Answer 22

a) 2.5 cm
b) less than 3.5cm
c) less than 4.5
d) greater than 5.5 cm

Question 23

what is your stereotypical at risk patient of AAA

Answer 23

males that are 60 years or older who are hypertensive, smokers and have a FH of AAA

Question 24

what are the main surgical options for AAA and what are the cons of each one

Answer 24

1. open surgery: replace the affected segment with plastic graft, rube or bifurcate
   - major cardiovascular stress and mortality is 5%
2. end-vascular surgery/repaire (EVAR): reline the aorta
   - only 70% of aneurysm are suitable for this type of treatment and a lot of people get an endoleak

Question 25

what triad would make you think of an AAA rupture

Answer 25

collapse hypotension lower back/flank pain

Question 26

After correction of an AAA, what are the two most common causes of mortality

Answer 26

acute renal insufficiency | myocardial infarction

Question 27

How do you define shock

Answer 27

acute clinical syndrome initiated by ineffective perfusion and cellular hypoxia, resulting in severe dysfunction of organs vital to survival

Question 28

what are the key features of shock

Answer 28

``` o Acute tissue/organ hypo-perfusion o Impaired delivery of oxygen to cells o Supply inadequate to meet demand o Generalised cellular hypoxia o Consequences for cellular respiration o Haemodynamic abnormalities but shock isn’t simply the presence of hypotension ```

Question 29

? x ? = cardiac output

Answer 29

HR X SV

Question 30

? X ? = mean arterial pressure

Answer 30

CO x vascular tone

Question 31

what are the 4 types of shock

Answer 31

hypovolaemic - reduced intravascular volume distributive- vasodilation and malperfusion cardiogenic- intrinsic cardiac (pump) failure obstructive- failure of circulatory flow

Question 32

give some examples of hypovolaemic shock

Answer 32

haemorrhage burns GI losses ( vomiting, diarrhoea, fistula) dehydration (heat exposure, polyuria DKA)

Question 33

give some examples of distributive shock

Answer 33

systemic inflammatory response syndrome (SIRS) related - sepsis, pancreatitis, trauma, burns neurogenic- spinal cord injury Anaphylacxis

Question 34

give some examples of cardiogenic shock

Answer 34

myocardial infarction/ischaemia arrhythmia acute valve pathology.

Question 35

give some examples of obstructive shock

Answer 35

tension pneumothorax pericardial tamponade pulmonary embolism

Question 36

what is the physiological response of hypovolaemia

Answer 36

* Sympathetic system activated (via the baroreceptors) * Adrenal catecholamine release * Compensatory cardiovascular responses * Sodium and water retention * Coagulation system activation * Cortisol release

Question 37

Give some signs of organ hypo-perfusion

Answer 37

o Skin o Oliguria o Cognitive changes o Metabolic acidosis

Question 38

Give some examples of crystalloids

Answer 38

normal saline hartmanns ringers lactate glucose solutions

Question 39

give some examples of colloids

Answer 39

``` Gelofusine starch dextran blood plasma platelets ```

Question 40

in shock what are the important diagnosises that need to be ruled out

Answer 40

tension pneumothorax pericardial tamponade PE Acute MI

Question 41

what medication can you give to increase the contractility of the heart

Answer 41

ionotropes

Question 42

A massive transfusion is defined as more than _____ bags in 24 hours or more than ______ bags in one hour

Answer 42

10 bags in 24 hours | 4 bags in an hour

Question 43

Which pathway does the PT time look at

Answer 43

extrinsic pathway - increased in liver disease

Question 44

which pathway does the APTT time look at

Answer 44

intrinsic pathway

Question 45

for clotting to occur what 2 cells do you need in your body

Answer 45

- one with TF (which is usually hidden in a healthy blood vessel) such as fibroblasts and macrophages - platelets

Question 46

what is DIC

Answer 46

disseminated intravascular coagulopathy - unregulated clots and lysis - blood clots form within the blood vessel and as clotting factors and platelets are used up, bleeding may occur

Question 47

whilst on ICU what is a patient at risk of developing after a massive haemorrhage

Answer 47

acute lung injury renal dysfunction DIC

Question 48

What is the issue with clotting associated with massive blood transfusion

Answer 48

dilution of platelets and clotting factors are recognised causes • Transfused associated acute lung injury (TRALI) • Transfusion associated circulatory overload (TACO)

Question 49

what are the main issues associated with prolonged stay on ICU

Answer 49

``` o Muscle weakness and wasting o Nutritional deficiencies o Sleep disorders o Inability to swallow effectively and micro aspiration of food o Recurrent chest infections ```