Abdominal Aortic Aneurysm

Question 1

what are the differentials for severe abdo pain, sudden onset, radiating to the back?

Answer 1

perforated viscus
acute pancreatitis
biliary colic
acute mesenteric occlusion

ruptured AAA

Question 2

what are the 3 main branches of abdominal aorta

Answer 2

super mesenteric, inferior mesenteric and coeliac trunk

Question 3

how does CO and BP change in patient who is losing blood?

Answer 3

o Body is able to maintain pressure at expense of CO and tissue BF until a large blood volume has been lost
o Only when compensatory mechanisms are unable to cope that BP begins to fall
o Hence, any person esp young and well, who have low BP in the context of acute blood loss are EXTREMELY ill and need urgent care

Question 4

what is an AAA and what is a ruptured AAA?

Answer 4

dilated abdominal aorta

aneurysm pops and starts bleeding into the abdominal cavity

Question 5

what is an aneurysm?

Answer 5

dilatation of ALL layers of the arterial wall and most are caused by degenerative disease

loss of intima and elastic fibres in media and associated with lymphocytic infiltration

Question 6

what are the risk factors for a AAA?

Answer 6

smoking
HTN
diabetes 
age >60
being male 4:1
caucasian 
FH 
connective tissue disease such as marfans

Question 7

how does a AAA present

Answer 7

often asymptomatic

symptoms of peripheral vascular disease

non specific abdo pain

visible or palpable pulsation

Question 8

how do you investigate for a AAA

Answer 8

USS or angiography CT or MRI

examine pulse in all limbs (aneurysm in popliteal also likely)

Question 9

how do you treat a triple A?

Answer 9

treat reversible risk factors
monitoring size
treat peripheral arterial disease
surgery

Question 10

what surgery is done for AAA

Answer 10

endovascular stenting (into abdominal aorta to prevent blood from collecting in the aneurysm)

complication = endo-leak

laparoscopic repair and open surgical repair

can also clamp the artery

Question 11

what happens in a ruptured triple A

Answer 11

risk of rupture increases with diameter

high mortality

presents with pulsatile mass and severe abdo pain, haemodynamic instability, may have generalised shock state and bilateral leg ischaemia

NO delay for imaging, diagnosis of rupture can be confirmed by immediate CT abdomen

Question 12

what other aneurysms may you see?

Answer 12

thoracic, suprarenal, popliteal

Question 13

what is the management of major haemorrhages?

Answer 13

recognise blood loss
resuscitate and call for help
stop the bleeding (pressure, reverse anti-coagulants, transexamic acid)
blood samples: group and save then cross match = give blood components as necessary
massive haemorrhage packs (1 and 2)
monitor coagulation tests and move to goal directed

Question 14

what massive haemorrhage packs 1 and 2

Answer 14

pack 1: 4 units of RBC and 4 units of FFP

pack 2: (given if MH continues)
- 4 units RBC, 4 units of FFP, 1 dose of platelets and 2 packs cryoprecipitates)

Question 15

what is the patient at risk of after the MH is under control?

Answer 15

patient will be at risk of thrombosis and will require thromboprophylaxis

Question 16

what is peripheral vascular disease?

Answer 16

atherosclerosis in arteries, can be chronic limb ischaemia or acute limb ischaemia

Question 17

what is claudication

Answer 17

pain on exertion due to ischaemia, predictable pain that settles swiftly at rest

Question 18

what is chronic limb ischaemia

Answer 18

ulceration, limb loss as well as rest pain

Question 19

what is acute ischaemia

Answer 19

emboli, dissection, large vessel thrombosis and the 6 p’s

Question 20

what are the 6ps?

Answer 20

pale, perishing cold, pulseless, painful, paraesthetic and paralysed (the last 2 are threatening and then non-viable meaning amputation)

Question 21

what are the risk factors for peripheral vascular disease?

Answer 21

increasing age, male sex, FH

smoking, HTN, cholesterol and diabetes

Question 22

what are the 4 stages of chronic limb ischaemia

Answer 22

o Fontaine 1: asymptomatic
o Fontaine 2: claudication
o Fontaine 3: rest pain
o Fontaine 4: tissue loss

Question 23

what is rest pain

Answer 23

o Icy, burning, constant pain in foot
o Worse in evening or elevation due to drop in BP and perfusion pressure in foot is less so wakes them up
o Needs opiates
o Needs this for 2 weeks before diagnosed as critical limb ischaemia

Question 24

what is tissue loss

Answer 24

gangrene and ulceration

Question 25

what is the treatment for PVD

Answer 25

``` o STOP SMOKING o Antiplatelets – aspirin o BP control o Cholesterol reduction – statin o Regular exercise o Lose weight o Tight diabetic control ```

Question 26

what is the prognosis for PVD

Answer 26

improves over 6-12 months | MI in next 5 years risk is 30%

Question 27

what is cerebrovascular disease

Answer 27

atheroma in carotid artery, presenting with stroke, TIA or amaurosis investigation is duplex for carotid artery stenosis or angiography, MR/CT treatment is carotid endarterectomy for symptomatic patients >70% stenosis in ICA is an indication for surgery

Question 28

what is an aortic dissection

Answer 28

Life-threatening condition: separation in layers of artery wall Tear in tunica intima; causes blood to flow between layers of the wall of the aorta Creating false lumen in the aorta

Question 29

what part of aorta does an AD commonly affect

Answer 29

surrounding ascending and aortic arch surgical emergency

Question 30

what are the RF for AD

Answer 30

chronic hypertension, connective tissue disorders such as ehler-danlos, marfans male, age >65, trauma

Question 31

how does an AD present

Answer 31

``` o Tearing chest pain of sudden onset o Sweating, nausea, SOB and weakness o Radiating to the back o Hypertension o Hypotension as dissection becomes more severe = shock ```

Question 32

how can you classify an AD

Answer 32

type A: involve the artery before origin of left subclavian, requires surgery type B: descending thoracic, medically treated

Question 33

how do you manage an AD

Answer 33

resusc, confirm by imaginng: first line is CT with contrast urgent surgery: stenting

Question 34

what is shock

Answer 34

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

Question 35

what is the basic cardio physiology?

Answer 35

learn notes

Question 36

what are the 4 types of shock?

Answer 36

Hypovolaemic = reduced intravascular volume due to fluid loss Eg haemorrhage, burns, GI losses, dehydration • Cardiogeneic – intrinsic cardiac failure of such severity that organ perfusion is compromised eg MI, arrythmias • Distributive – vasodilation and malperfusion eg Sepsis, pancreatitis, trauma, anaphylaxis, neurogenic • Obstructive – failure of circulatory flow eg Tension pneumothorax, pericardial tamponade, PE

Question 37

what are the physiological responses to shock?

Answer 37

* Preload falls  SV falls  CO falls * To compensate, SNS activates SAN  tachycardia and increased contractility  SVR or vascular tone increased  offset reduction in mean arterial pressure

Question 38

what would you see in a person with shock?

Answer 38

cold and pale skin oliguria confusion and lethargy possibly metabolic acidosis

Question 39

how do you manage shock

Answer 39

``` ABCDE oxygen fluids IV; 2 large bore cannulae bloods: crossmatch ABG treat cause eg MH ``` aim to prevent irreversible organ failure and injury

Question 40

what is a crystalloid

Answer 40

contains electrolytes dissolved in water eg normal saline, hartmanns electrolytes and water distribute easily into ECF so much doesnt stay intravascularly

Question 41

what is a colloid

Answer 41

large molecules inelectrolyte solution | useful for patients who need a quick increase in circulating volume

Question 42

what is septic shock

Answer 42

widespread inflammation due to infection vasodilation and capillary leak

Question 43

what are the complications of a massive blood transfusion

Answer 43

Transfusion-related acute lung injury (TRALI) - Rare but serious syndrome (1 in 12,000) characterised by sudden acute respiratory distress following transfusion. new acute lung injury (ALI) during or within 6 hours after blood product administered hence req careful coagulation monitoring

Question 44

what other complications may you see after a transfusion

Answer 44

infection hypocalcaemia (bc citrate binds to calcium) haemolytic reactions (rhesus status; due to mismatched blood) hypothermia allergy / anaphylaxis

Question 45

what would you see an an acute haemolytic transfusion reaction

Answer 45

fever, abdominal and chest pain, agitation and hypotension

Question 46

what is a non-haemolytic febrile reaction

Answer 46

due to WBC HLA antibodies, use paracetamol

Question 47

what problems will someone in the ICU have when they are discharged?

Answer 47

``` muscle weakness and wasting nutritional deficiencies sleep disorders inability to swallow effectively microaspiration of food recurrent chest infections ```