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Surgery.(General 2).Vascular > Arterial.2.Acute ischemia > Flashcards

Arterial.2.Acute ischemia Flashcards

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1
Q

DEFINITION of LIMB ISCHEMIA

A

Ischemia means diminished arterial blood sufficient to interfere with nutrition of the part.

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2
Q

ETIOLOGY of Ischemia

A

A) Acute Ischemia

B) Chronic Ischemia

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3
Q

All causes of acute ischemia

A
  1. Embolism “acute embolic ischaemia” : Commonest cause.
  2. Acute thrombosis “acute thrombotic ischaemia”
  3. Arterial injuries.
  4. Dissecting aneurysm.
  5. Phlegmasia cerulae or alba dolens.
  6. Arterial spasm due to ergot poisoning

7 : lntra-arterial injection.

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4
Q

All causes of chronic ischemia

A
  1. Atherosclerosis (commonest cause).
  2. Diabetic presenile atherosclerosis.
  3. Buerger’s disease.
  4. Vasospastic conditions
  5. Incomplete recovery after treatment of acute ischemia
  6. Aneurysm.
  7. Vascular compression : Thoracic outlet syndrome
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5
Q

Definition of acute ischemia

A

lt is SUDDEN decrease in arterial limb perfusion causing THREAT to limb vitality

No time for collaterals formation and gangrene occurs in 24 hours.

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6
Q

The Problem about acute ischemia

A

No time for collaterals formation and gangrene occurs in 24 hours.

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7
Q

Clinical picture of acute ischemia 6P

A
  1. Pain
  2. Paresis & muscle weakness “early” passing to paralysis “late”.
  3. Paraesthesia & numbness “early” followed by sensory loss “late”.
  4. Pulselessness : The distal pulsations are lost.
  5. Pallor “early”, then mottling & cyanosis “late”.
  6. Progressive coldness is an early symptom.
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8
Q

Pain in Clinical picture of acute ischemia

A
  • onset
  • character
  • site and radiation
  • what increase.
  • what decrease
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9
Q

onset of Pain in Clinical picture of acute ischemia

A

sudden onset.

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10
Q

character of Pain in Clinical picture of acute ischemia

A

Bursting or stabbing in character.

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11
Q

site and radtiation of Pain in Clinical picture of acute ischemia

A

Starts at the point of occlusion and shoots distalty

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12
Q

what increase.Pain in Clinical picture of acute ischemia

A

movement and warmth.

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13
Q

what decrease Pain in Clinical picture of acute ischemia

A
  • Pain may diminish in intensity by time if
  • collaterals open improving the circulation “as in cases of acute thrombotic ischemia”

OR

  • ischemia progresses causing ischemic sensory loss.
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14
Q

the reason why the pain in acute ischemia is bursting

A

Accumultion of metabolites ~~ V.D ~~ severe interstial edema ~~ bursting pain

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15
Q

collateral occur in which type of acute ischemia

A

acute thrombotic type

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16
Q

Paresis & muscle weakness “early” passing to paralysis “late” in Clinical picture of acute ischemia

A

1st muscle group affected by acute ischemia

The reason why detection of early muscle weakness is difficult in acute ischemia

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17
Q

1st muscle group affected by acute ischemia in Clinical picture of acute ischemia

A

intrinsic foot muscles followed by the leg muscles

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18
Q

the reason why detection of early muscle weakness is difficult in acute ischemia

A

because toes movements are produced mainly by leg muscles.

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19
Q

Paraesthesia & numbness “early” followed by sensory loss “late”. in Clinical picture of acute ischemia

A

order of frequency of sensory affection :

  1. Light (Crude) touch
  2. Vibration sense.
  3. Proprioception.
  4. Deep pain “late”.
  5. Pressure sense “late”
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20
Q

First to be affected from sensory due to acute ischemia

A

Light (Crude) touch

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21
Q

meaning of mottling

A
  • V.D of vessels by Accumulation of metabolites

* Extravasation of RBCs due to ischaemic endothelial damage

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22
Q

Complications of acute ischemia

A
  1. Extension thrombosis
  2. Muscle necrosis occurs after 6-12 hours.
  3. Moist aseptic gangrene :
  4. Chronic ischaemia in low level occlusion only.
  5. Reperfusion syndrome :
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23
Q

Pathogenesis of Extension thrombosis in Complications of acute ischemia

A

After circulatory arrest )> widespread distal intravascular thrombosis

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24
Q

Moist aseptic gangrene in acute ischemia

A

Pathogenesis

the reason why it’s moist

the reason why Development of collaterals may fail in acute ischemia

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25
pathogenesis of Moist aseptic gangrene in acute ischemia
If occlusion is not relieved by surgical intervention or the collaterals are inadequate, the thrombosis extends further & the ischaemic changes progress to moist aseptic gangrene within 24 hours.
26
the reason why gangrene in acute ischemia is moist gangrene
Accumultion of metabolites ~~ V.D ~~ severe interstial edema
27
Development of collaterals may fail in acute ischemia due to
a. Reflex vasoconstriction of collaterals. | b. Spreading thrombus in the collaterals.
28
the reason why Chronic ischaemia complicates acute ischemia in low level occlusion only.
Infra popliteal region is supplied by 3 vessels
29
Etiology of Reperfusion syndrome in complication of acute ischemia
a. compartmental syndrome b. cardiac arrhythmia or cardiac arrest c. crush syndrome
30
compartmental syndrome in complication of acute ischemia
* Definition * in a phrase * pathogenesis * Treatment
31
Definition of compartmental syndrome in complication of acute ischemia
Means increased pressure in a closed fascial compartment (e.g, the anterior compartment of the Ieg) more than pressure needed for tissue perfusion.
32
compartmental syndrome in a phrase
acute ischemia with a pulse as the capillary bed is occluded
33
pathogenesis of compartmental syndrome in complication of acute ischemia
* Released inflammatory mediators as a result of muscle ischemia causes vasodilatation of the blood vessels & damage of the endothelial lining. * Later on after perfusion, severe edema occurs raising the pressure in the closed compartment
34
Treatment of compartmental syndrome in complication of acute ischemia
Fasciotomy
35
cardiac arrest and cardiac arrhythmia in complication of acute ischemia
pathogenesis Treatment
36
pathogenesis of cardiac arrest and cardiac arrhythmia in complication of acute ischemia
Due to flooding the circulation with: * excess acid metabolites (resulting from anaerobic metabolism of the tissues) * excess potassium from cell damage.
37
Treatment of cardiac arrest and cardiac arrhythmia in complication of acute ischemia
with NaHCO3 + Glucose-insulin infusion to stimulate intracellular shift of K+
38
crush syndrome in complication of acute ischemia
Pathogenesis Treatment
39
Pathogenesis of crush syndrome in complication of acute ischemia
Acute tubular necrosis due to release of myoglobin from ischaemic muscles which the blocks renal tubules leading to acute renal failure.
40
Treatment of crush syndrome in complication of acute ischemia
mannitol infusion & dialysis if anuria developed
41
Definition of acute embolic ischemia
Embolism means sudden impaction of an embolus in a relatively healthy arterial tree causing obstruction & loss of function.
42
sources of Embolism
(A) cardiac: (B) Arterial wall :
43
cardiac sources of Embolism
1. Left atrium in atrial fibrillation. 2. Left ventricle after recent myocardial infarction 3. Thrombi may form on prosthetic valves 4. The valves in S.B.E
44
Arterial wall sources of Embolism
The aorta from an aneurysm
45
Site of impaction of an embolus is Bifurcation of vessels due to :
* Decrease in diameter. * Slowing of the circulating blood. * Turbulence.
46
Commonest site of impaction of an embolus ; In order of frequency
Common femoral bifurcation Aortic bifurcation. Popliteal bifurcation.
47
Saddle embolus
Embolus impacted at aortic bifurcation.
48
Clinical picture of acute embolic ischemia | Very important
6P + clinical features suggestive of acute embolism
49
clinical features suggestive of acute embolism
1. Sudden onset of symptoms. 2. Known source of emboli. 3. No previous history of claudication pain & chronic ischaemia. 4. Normal pulse in the other limb or A.F.
50
D.D of acute embolic ischemia
Commonly, acute thrombosis arises in an artery previously narrowed by atherosclerosis
51
Difference between acute embolism and acute thrombosis is done by
Age Past history Commonest site. Radial pulse. Pulse in other limb. Arteriography.
52
Age of acute embolism
Commoner in young age
53
Age of acute thrombosis
Commoner in old age
54
Past history of acute embolism
Cardiac troubles
55
Past history of acute thrombosis
Intermittent claudication
56
Commonest site of acute embolism
Bifurcation of common femoral artery
57
Commonest site of acute thrombosis
Lower end of femoral artery.
58
Radial pulse of acute embolism
A.F (commonest cause).
59
Radial pulse of acute thrombosis
Usually regular.
60
Pulse in other limb of acute embolism
Normal.
61
Pulse in other limb of acute thrombosis
Weak.
62
Arteriography of acute embolism
Minimal collaterals
63
Arteriography of acute thrombosis
Exlensive collaterals
64
commonest cause of acute emoblism
A.F
65
Investigations of acute embolic ischemia
1. Arterial duplex scanning.: 2. ECG, echocardiography. 3. Arteriography usually not needed better to be done intraoperative
66
Arterial duplex scanning in Investigations of acute embolic ischemia, show
Inaudible arterial signals at the level of obstruction.
67
Postgraduate note : The presence of pedal signals in Arterial duplex scanning in Investigations of acute embolic ischemia, usually indicates
that there is time for conventional arteriography & proper patient preparation.
68
Arteriography in Investigations of acute embolic ischemia
indications value of Pre-operative arteriography
69
Indications of Arteriography in Investigations of acute embolic ischemia
* usually not needed better to be done intraoperative * Pre-operative arteriography in acute ischemia is done ONLY If differentiation between acute embolic ischemia & acute thrombotic ischemia is not clear clinically provided that the condition of the limb permits
70
value of Pre-operative arteriography in Investigations of acute embolic ischemia
a) Localizes the exact site of obstruction. b) Visualizes the arterial tree & distal run-off. c) Can diagnose an embolus by:
71
Pre-operative arteriography in Investigations of acute embolic ischemia can diagnose an embolus by :
1) Sharp cut-off 2) Reversed meniscus sign 3) Clot silhouette.
72
Reversed meniscus sign
Crescentic filling defect in arteriography of actue ischemia
73
Clot silhouette.
Its Shadow Filling defect in arteriography of actue ischemia
74
Treatment of acute embolic ischemia
(A) General rules (B) Immediate Embolectomy (C) prevention of complications (D) Prevention of further emboli (E) Delayed embolectomy (F) Amputation
75
General rules in treatment of acute embolic ischemia
* Immediate heparinisation : (most important) * Appropriate analgesia. * Start TTT of associated cardiac condition as A.F * Simple measures to increase existing perfusion :
76
the reason why we do immediate heparinisation in General rules in treatment of acute embolic ischemia
To prevent propagation of thrombosis
77
Simple measures to increase existing perfusion in General rules in treatment of acute embolic ischemia
i) Keep the foot dependant. ii) Avoid extremes of temperature (cold induces vosospasm & heat raises the metabolic rate iii) Maximum tissue oxygenation
78
most important General rule in treatment of acute embolic ischemia
Immediate heparinisation
79
Immediate Embolectomy in treatment of acute embolic ischemia
Procedure Indications Signs of adequate embolectomy Complications Prognosis:
80
Procedures of Immediate Embolectomy in treatment of acute embolic ischemia
Using Fogarty balloon catheter: | It is done under local anesthesia.
81
Indications of Immediate Embolectomy in treatment of acute embolic ischemia
Done as long as the limb is viable. * no fixed mottling. * No muscle turgor. * Intact capillary circulation.
82
indications of viable limb in cases of acute embolic ischemia
* no fixed mottling. * No muscle turgor. * Intact capillary circulation.
83
Signs of adequate embolectomy in Immediate Embolectomy in treatment of acute embolic ischemia
1. Back bleeding. . 2. Pulses are felt during the operation. 3. Intraoperative angiography.
84
Complications of Immediate Embolectomy in treatment of acute embolic ischemia
1. Rupture of the artery. 2. Dissection. 3. Distal embolization
85
Prognosis of Immediate Embolectomy in treatment of acute embolic ischemia
Removal of embolus within 6-10 hrs of onset of symptoms can result in saving the limb completely
86
Prevention of complications in treatment of acute embolic ischemia
Fasciotomy NaHCO3 + Glucose-insulin infusion mannitol infusion & dialysis if anuria developed.:
87
the reason why we do Fasciotomy
To prevent compartmental syndrome
88
the reason why we give NaHCO3 + Glucose-insulin infusion
To stimulate intracellular shift of K+ : To prevent cardia arrest and cardiac arrhythmia
89
the reason why we give mannitol infusion & dialysis if anuria developed
to prevent crush syndrome
90
Prevention of further emboli in treatment of acute embolic ischemia
1. Long term anticoagulants e.g. warfarin. | 2. Treatment of the underlying cause whenever possible.
91
indication of delayed embolectomy
If the patient is presented after 24 hours It's done to save the profunda femoris artery & hence a safe AKA.
92
Amputation in treatment of acute embolic ischemia
indications Rule
93
indications of Amputation in treatment of acute embolic ischemia
irreversible ischemia with permanent tissue damage
94
Permanent tissue damage in acute embolic ischemia is known by
turgid muscles or fixed mottling & cyanosis
95
turgid muscles
Like rigor mortis
96
Pathogenesis of fixed mottling in Permanent tissue damage in acute embolic ischemia
Thrombosis reached vasodilated skin blood vessels
97
Rule of amputation in treatment of acute embolic ischemia
Palpable popliteal pulse)> Below knee amputation "BKA". Absent popliteal pulse)> Above knee amputation "AKA".
98
ETIOLOGY of acute thrombotic ischemia what changes the condition from chronic to acute
* Atherosclerosis. * Typhoid fever. * Polycythaemia. * Dehydration e.g. with diarrhea. * Prolonged immobilization.
99
Clinical picture of acute thrombotic ischemia
6Ps + previous history of chronic ischaemia.
100
the reason why acute thrombotic ischemia is less severe than acute embolic ischaemia.
Collaterals are more developed in patients with preexisting chronic ischemia
101
Investigations of acute thrombotic ischemia
1. Arterial duplex scanning. 2. Urgent arteriography is a MUST. 3. ECG, echocardiography.
102
the reason why Urgent arteriography is a MUST in case of acute thrombotic ischemia
To detect run off If present )> by pass surgery
103
Treatment of acute thrombotic ischemia
Acute arterial thrombosis is an emergency. 1. Bypass graft 2. lntra-arterial thrombolysis by streptokinase, urokinase or TPA is another option of treatment:
104
indications of Bypass graft in Treatment of acute thrombotic ischemia
if there is good run-off.
105
Indications of lntra-arterial thrombolysis by streptokinase, urokinase or TPA
* if there is no run-off. | * High risk patient for bypass graft.

Surgery.(General 2).Vascular (16 decks)

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