IPE Flashcards
(176 cards)
1
Q
What routes of anesthetics should be avoided in those that are on anticoagulants?
A
Spinal, epidural and local nerve blocks
2
Q
What is important about B blockers?
A
Should be continued on the day of surgery to prevent a labile response during surgery
3
Q
What is important about digoxin pre surgery?
A
Continue up to and including morning of surgery
check for toxicity levels and do plasma K and Ca
Suxemethionium can lead to increased K and therefore ventricular arrhythmias
4
Q
When can a patient last eat and drink before surgery?
A
Eat 6 hours and clear fluids 2 hours
5
Q
When are compression stocking contraindicated?
A
PVD
6
Q
What is the dose of heparin for prophylaxis for the average patient?
A
5000u
7
Q
When is a CXR indicated before surgery?
A
known Cv disease, pathology or symptom
>65year old
8
Q
When is an ECG indicated before surgery?
A
> 55y/o
poor exercise tolerance
history of MI, hypertension, rheumatic fever or other heart disease
9
Q
when should a lateral cervical spine XR be done?
A
history of RA, ankylosising spondylitis or downs in preparation for a difficult intubation
10
Q
What are the different types of surgery in terms of risk of infection?
A
Clean
Clean -contaminated
Contaminated
Dirty
11
Q
What is meant by a clean surgery?
A
Incising infected skin without breaking any viscera
12
Q
What is meant by clean contaminated surgery?
A
Intraoperative breach of viscera but not the colon
13
Q
What is meant by contaminated surgery?
A
Breach of viscus and spillage/ opening of the colon
14
Q
What is meant by dirty surgery?
A
Site is already contaminated by pus or faeces or exogenous sourrce
15
Q
What are the different types of suture material?
A
Absorbable and non absorbable
synthetic or natural
monofilament, twisted or braided
16
Q
What determines when sutures can be removed?
A
The site and the health of a patient - need longer in the elderly and smokers due to poorer healing
17
Q
What is the function of premedication before surgery and anasethetics?
A
Allay anxiety and make anaesthesia easier to conduct
18
Q
Explain a typical pre medication before surgery
A
Anxiolytic- given 2 hours pre surgery - Midazolam preferrred in children
Analgesia - aims to dampen down pain before starts
Antiemetic- ondansetron known to be the most effective
Antacid - reduce the aspiration risk
Antiobiotics may be considered depending on the surgery
19
Q
What are the side effects of hyoscine and atropine?
A
Antimuscarinic and therefore tachycardia, urinary rentention, glaucoma and sedation
20
Q
What are the side effects of propofol?
A
Respiratory and cardiac depression
pain on injection
21
Q
What are the complications of anaesthetics?
A
Pain sensation- pressure necrosis, retention, local nerve damage
Consciousness - cannot inform if something is wrong
Muscle power - corneal abrasion, no cough which can lead to impaired gas exchange
22
Q
What are the advantages of local nerve blocks?
A
Allow patients to have surgery when a local anaesthetic is contraindicated
23
Q
What is malignant hypertension?
A
Autosomal D condition
Rapid rise in temperature leading to hypoxaemia, hypercabia, hyperkalaemia, metabolic acidosis and arrhythymias
Prompt treatment with Dantrolene, active cooling and ITU
24
Q
What antibiotic prophylaxis can be given before an appendicectomy, colorectal resections and open biliary surgery?
A
Single dose of IV tazobactam
Gentamicin + metrondiazole
Co Amoiclav
25
What antibiotic prophylaxis can be given for oesophogeal or gastric surgery?
IV gent
Piperacillin/ tazobactam
Co Amox
26
What antibiotic prophylaxis given before vascular surgery?
IV Piperacillin/ tazobactam
| Or flucloxacillin +metrondiazole if anaerobes
27
What prophylaxis is done for patients with MRSA?
high risk add teicoplanin or vanc to protocol
28
What is the maximum dose of lidocaine that can be given to a 70kg man at different strengths?
0.25% - 80ml
0.5% - 40ml
1- 20ml
2-10ml
29
What is the approach to pain?
Identify the cause and treat if possible
Give regular doses rather than as required
Chose the best route
Explaination and reassurance is helpful to reducing pain
Allow patient to be in charge and liase with acute pain service
30
When should NSAIDs be prescribed with caution?
Asthma, renal and hepatic impairment
heart failure
IHD
pregnancy and the elderly
Aspirin is contraindicated in the young at risk of Reye's syndrome
31
What is given to reverse an over dose of opioids?
Naloxone
32
Explain the WHO pain ladder
Google
33
What is usually the cause of pyrexia within the first 48 hours post op?
Basal acelectasis
34
What are the causes of HTN post op?
Pain, urinary retention, idopathic hypertension or iontropic drugs
35
What might be causes of oligouria post op?
blocked or mal sited catheter
increased fluids given
check for a palpable bladder as may be in rentention
36
Why is metaclompramide not indicated in patients with post op nausea and vomitting?
Pro kinetic features which may make
37
How can post op complications be classified?
From anaesthetic
From surgery in general
From specific procedure
38
What are the risk factors for DVT?
increased age, pregnancy, synthetic oestrogen, trauma, surgery, past DVT, cancer, obesity
39
When is D dimer raised?
infection, post surgery, malignancy, thrombosis and pregnancy
40
What are differentials for a DVT?
cellulitis and ruptured bakers cyst
41
What are the differentials for bilateral swollen legs?
systemic disease with increased venous pressure or decreased intravascular oncotic pressure
- RHF
- decreased albumin in renal or liver failure
- Venous insufficiency
- Vasodilators - Ca channel blockers
- pelvis mass
- pregnancy (pre-eclampsia)
42
What is meant by wound dehiscence? How is it managed?
Break down of a wound after lapratomy which may lead to bowel outside the abdomen
Management includes calling a senior, pushing the bowel back in, covering with a sterile dressing and give IV Abx and return to theatre.
43
What are the risk factors for wound dehiscence?
elderly, malnourished, if infection, uraemia, or haematoma present
44
What are the early complications of biliary surgery?
```
Iatrogenic bile duct injury
Cholangitis
bile leakage
bleeding
Pancreatitis
```
45
What are the late complications of biliary surgery?
Bile duct stricture
| post cholecystectomy syndrome - symptoms arising from the alterations in bile flow due to loss of reservoir
46
What are the early complications of thyroid surgery?
Recurrent and superior laryngeal nerve
thyroid storm
tracheal obstruction due to haematoma - needs immediate removal of the sutures
hypoparathyroidism
47
What are the late complications of thyroid surgery??
Hypothyroidism
| recurrent hyperthyroidism
48
What are the complications of aortic surgery?
Gut ischaemia
Renal failure
respiratory distress
trauma to ureters or anterior spinal artery
ischaemic events from distal emboli from dislodged thrombus
Bowel aortic fistula
49
What are the early complications of stomas?
```
Haemorhage at stoma site
Stoma ishaemia
High output - consider loperamide and codeine to thicken
Obstruction secondary to adhesions
Stoma retraction
```
50
What are the late complications of stomas?
```
obstruction
dermatitis at stoma site
stoma prolapse
stoma intussusception
stenosis
paratomal hernia
fistulae
psychological problems
```
51
How do we assess if a patient is malnourished?
MUST score
52
What must be done before feeding through a nasogastric tube?
CXR - check in the right location before feeding or feed may go into the lungs if tube is malsited
53
How is TPN given?
via a dedicated central venous line or PICC line or via a dedicated lumen of a multi-lumen catheter
54
What are the complications of TPN?
Sepsis - staph aureus, Staph epidermis, candidia)- line must be taken out
Thrombosis - may result in PE or SVC obstruction
Metabolic imbalance - refeeding syndrome and deranged LFTs
Mechanical - pneumothorax on line insertion
55
Explain the pathophysiology behind refeeding syndrome
After a long period of starvation, insulin levels fall to low levels and then on carbohydrates been taken in increased insulin leads to increased phosphate and low serum levels.
Features include rhabdomylitis, red and white cell dysfunction, respiratory insufficiency, arrhythymias, cardiogenic shock and seizures
56
What HbA1c should be aimed for in a diabetic before surgery?
<69mmol/mol
57
What should be done for an IDDM patient before they have surgery?
Place first on the list to reduce the fasting time
Give all usual insulin the day before surgery
Long acting insulin is usually normally continued at normal time even when patients are on variable insulin infusion
If on the morning list - ensure no subcutanous insulin is given in the morning. If afternoon list give the morning dose.
If not eating normally and high levels a variable rate insulin infusion will be needed.
58
What should be done for an NIDDM patient before they have surgery?
If diabetes is poorly controlled treat as patients on insulin
Give all usual medication night before surgery except long acting sulphonylureas which can cause hypoglycaemia on fasting
If on morning list - omit morning dose and give with lunch and if on afternoon list normal morning dose and take any missed doses with late lunch.
59
Explain what must be considered when prescribing metformin and contrast
Metformin can be continued after IV contrast as long as GFR >60ml/L and normal serum creatinine.
To minimise the risk of nephrotoxicity if serum creatinine is raised or GFR <60 - omit metformin for 48hours and check renal function
60
What should diabetic patients have pre surgery?
Screen for asymptomatic cardiac and renal disease
| be aware of silent MIs post op
61
How do you write up variable rate insulin infusion on a prescription?
Prescribe 50u of short acting insulin in 50mL of 0.9% saline to infuse at the rate dependent on BM
Fluid should also be prescribed to run through with the VRII.
62
What needs to be taken into account in patients under going surgery with jaundice?
Dont operate on a patient who is obstructively jaundice - do ERCP first
Coagulopathy - Vit K decreased in obstruction- if no history of liver disease give parentral vit K
Increased risk of sepsis due to increased bacterial translocation, bacterial colonisation of the biliary tree and decreased neutrophil function
increased risk of renal failure- ensure adequate fluids and monitor renal output
63
When are antibiotic indicated post ERCP?
```
biliary tree decompression fails
history of biliary disorders
liver transplant
presence of pancreatic psuedocyst
neutropenia
```
64
When should warfarin be before surgery?
5 days before
65
What is important to remember in those on steriods undergoing surgery?
Patients who are adrenal suppressed through the use of steroids may not be able to increase steroids needed post op
May need a bolus and increase in dose post op for a short time frame
66
What are some cautions to day surgery?
```
Severe dementia
Severe LD
Living alone
Children if supervision difficult
BMI >32
ASA greater than 3
infection at the site of operation
```
67
What are the differentials for an intra dermal lump?
Sebaccous cyst
Abscess
dermoid cyst
Granuloma
68
What are the differentials for a subcutaneous lump?
Lipoma
Ganglion
Neuroma
Lymph node
69
What are the causes of a distended abdomen?
```
Fat
Faeces
Flatus
Fetus
Fluid
```
70
What are some differentials for RIF mass?
```
Appendix mass or abscess
caecal carcinoma
Crohns disease
Pelvis mass
TB mass
Transplanted kidney
undescended kidney
```
71
What are the different type of hepatomegaly?
Smooth- hepatitis, CCF, sarcoidosis, early hepatitis in alcoholics
Craggy- secondaries or primary hepatocellular carcinoma
Pulsating - tricuspid regurg
72
How do you know a mass is in the pelvis?
Cannot get below it
73
What signs are seen with someone who is peritonitic?
```
Lying still
positive cough test
rebound tenderness
Board like abdo rigidity
guarding
```
74
What is colic pain?
Regular waxing and waning pain caused by muscular spasm in a hollow viscus. causes restlessness
75
Explain the presentation of an appenditicitis
Periumbilical pain that moves to the RIF
| Tachycardia, fever, peritonism with guarding and rebound tenderness and percussion tenderness in RIF
76
What signs can be used to help with the diagnosis of an appendicitis?
Rovsings sign- pain is greater in the RIF when palpating the LIF
Psoas sign - pain on extending the hip if retroceacal appendix
Cope sign- pain on flexion and internal rotation of the right hip if appendix is in close proximity to the obturator internus
77
What tests can be done for appendicitis?
Blood tests will reveal neutrophil leukocyosis and elevated CRP
CT high diagnostic accuracy and is useful if diagnosis is unclear - reduced negative removal rate
78
What are the complications of appendicitis?
perforation - more common with faecolith
appendix mass
abscess
79
Explain the nerve and blood supply to the gut
For - to proximal 2nd part of the duodenum - epigastrium pain and coeliac trunk
Mid - above to 2/3 transverse colon - periumbilical- superior mesenteric
hind - distal to above- suprapubic - inferior mesenteric
80
What are the differentials of appendicitis?
```
Ectopic
UTI
mesenteric adenitis
cystitis
Crohns disease
perforated ulcer
Cholecystitis
```
81
What are the cardinal features of bowel obstruction?
Vomiting, nausea and anorexia
colic occurs early and can be complete constipation
abdo distention
82
What is the difference between ileus and mechanical obstruction?
Ileus is a functional obstruction from decreased motility whereas mechanical obstruction is a blockage of the actual tube
83
What is the immediate management of small bowel obstruction?
Drip and suck - NGT and IV fluids to rehydrate and correct any electrolyte imbalances
84
What imaging can be done for patient with BO?
CT establish the cause
| Oral gastrografin prior to CT to identify the level of the obstruction
85
When is emergancy surgery indicated in BO?
strangulated
86
What is a sigmoid volvulus?
Where the bowel twists around its mesentary which can produce severe rapid strangulate obstruction
87
How is a sigmoid volvulus managed?
Flatus tube or sigmoidoscopy
| rarely sigmoid colectomy requried
88
What is the management for a umbilical and a indirect inguinal hernia in a child?
Umbilical can be monitored as very few require surgery
| Indirect inguinal hernia - surgical repair required
89
What are the cause of acute mesenteric ischaemia?
Superior mesenteric artery thrombosis or embolism
Mesenteric vein thrombosis
non occulsive disease states such as low output states - shock
trauma, vasculitis, radiotherapy and strangulation
90
What is the presentation of acute mesenteric ischaemia?
Acute severe abdominal pain, no abdo signs and hypovolaemia
| pain tends to be constant and around the RIF
91
What will investigations show in a patient with acute mesenteric ischaemia?
```
increased Hb due to plasma loss
increased WCC
increased amylase
persistent metabolic acidosis - increased lactate
CT/ MRI signs of ischaemia
```
92
What is the treatment of mesenteric ischaemia?
surgery to remove necrotic bowel
| need LMWH, fluid, Abx
93
What are the complications of mesenteric ischaemia?
septic peritonitis
| Sepsis and multi organ failure
94
What is chronic mesenteric ischaemia?
severe colicky post prandial abdo pain, decreased weight and upper abdo bruit may be heard with PR bleeding
95
What is a common cause for chronic mesenteric ischaemia?
Atherosclerosis
96
What is the treatment for chronic mesenteric ischaemia?
once diagnosed should consider surgery due to ongoing infarct
percutaneous transluminal angioplasty and stent insertion
97
What are the physical complications of a gastrectomy?
Abdominal fullness - feeling early satiety and improving with time
Afferent loop syndrome - afferent loop may fill with bile causing pain and bilious vomiting
Diarrhoea - codeine phosphate may help
Gastric tumour
98
What are the metabolic complications of gastrectomy?
```
Dumping syndrome - fainting and sweating after eating due to food of high osmotic potiental being dumped in the jejunum and late dumping cause hypoglycaemia
weight loss from poor calorie intake
bacterial overgrowth and malabsorption
anaemia - lack of iron and B12
osteomalacia
```
99
When is surgery done for GORD?
Severe symptoms that are refractory to medical treatment and severe reflux is confirmed on mametry
100
What are the causes of oesophageal rupture?
```
Iatrogenic - OGD
Trauma - penetrating injury or indigestion of something sharp
Carcinoma
Boerhaave syndrome- violent vomitting
Corrosive indigestion
```
101
What are the signs and symptoms of oesophageal rupture?
Odynophagia, tachypnoea, dyspnoea, fever, shock, surgical emphysema
102
What is the management of oesophgeal rupture?
Iatrogenic - PPI, NG tube and antibiotics
| Surgery may be required for others
103
What are the indications for bariatric surgery?
```
BMI >40
failure of non surgical management to achieve and maintain clinical beneficial WL for 6 months
Fit for surgery and anaesthetics
Intensive management in tier 3 services
Patient well informed and motivated
```
If BMI >50 or in newly diagnosed T2DM with BMI >30 surgery is recommended as first line
104
What bariatric surgery can be done?
Laprascopic adjustable gastric banding
Sleeve gastrectomy
Roux- En - Y gastric bypass
105
What is the difference between diverticulum, diverticulosis, diverticular disease and diverticulitis?
diverticulum- out pouching of the gut wall usually at sites of entering arteries
diverticulosis- means diverticulae are present
diverticular disease- implies symptoms are present
diverticulitis- inflammation of a diverticulum
106
What is the best investigation to confirm acute diveriticulitis?
CT abdomen - also allows complications to be viewed
107
What are the complications of diverticular disease?
Perforation - laprascopic hartman's procedure performed
haemorhage - can cause large PR bleeds
Fistulae - Colovesical can present with pneumaturia and intractable UTIs
Abscesses - swinging fever, leucocytosis and localising signs
Post infective strictures
108
What is the management of an acute GI bleed?
A to E
Blood tests - FBC, U&Es, LFT, clotting, amylase, CRP and G&S
Imaging - only need a AXR but if signs of peritionitis erect CXR
fluid management - Fluid in and monitor output
Clotting - with hold anticoags and think about reversal
Abx - if signs of sepsis
Keep bedbound
start stool chart- send culture for MC&S
consider surgery in unremitting bleeding
109
What is pruritis ani? What causes it?
Itching of the anal region
| Caused by fissures, incontinence, tight pants, worm infections and lichen sclerosis, anxiety
110
What is a fissure in ano?
Painful tear in the squamous lining of the lower anal canal
111
What are the causes of a fissure?
most due to hard faeces
spasm may constrict the inferior rectal artery causing ischaemia and affecting healing
rare causes include syphilis, herpes, crohns, trauma, anal cancer
112
What is the management of a fissure?
Lidocaine and GTN onitment or topical diltazem
increase diet fibres and stool softeners
If all else fails can do a lacteral partial internal sphincterectomy
113
What is a fistula in ano?
Track communicates between the skin and anal canal- blockage of a deep intramuscular gland duct is thought to predispose to the formation of abscesses which discharge to form the fistula
114
Who's law dictates the path of a fistula?
Goodsalls' rule
115
What are the causes of a fistula?
```
Perianal sepsis and abscessess
Crohns
TB
Diverticular disease
Rectal cancer
```
116
What is the treatment for a fistula?
Fistulotomy and exicison
117
What are haemorrhoids?
Disrupted and dilated anal cushions - occur at 3,7, and 11 oclock where the three main vessels enter the anal canal
118
Why arent haemorrhoid painful?
Above the dentate line where there are no sensory fibres. When they thrombose become painful
119
What are the causes of haemorhoids?
Constipation with prolonged straining
| may have pelvic mass, pregnancy , CCF, or portal hypertension
120
What are the symptoms of haemorrhoids?
Bright red bleeding often coating the stools, on the tissues or dripping into the pan after pooing.
PR examination prolapsing piles are obvious, internal haemorhoids not palpable
121
What is the treatment of haemorrhoids?
1) Medical - increase fluid and fibre
2) non op - rubber band ligation, sclerosants
3) surgery - excisional haemorrhoidectomy and stapled haemorrhoidopexy
122
What is the management for thrombosed piles?
Analgesia, ice packed, and stool softeners, pain usually resolves in 2-3 weeks
123
What is the classification of haemorhoids?
1 st - remain in the rectum
2nd - prolapse through the anus on defaecation but spontaneously reduce
3 - require digital reduction
4- remain persistently prolapsed
124
What are the types of gallstones?
Pigment stones
Cholesterol stones
Mixed stones
125
What is Mirizzi syndrome?
A stone in the gallbladder pressures on the bile duct causing jaundice
126
What are the complications for pancreatitis?
Pancreatic necrosis and psuedocyst - fluid in lesser sac with a fever, mass and persistent increased amylase
Bleeding - from elastase eroding into a major vessel such as the splenic A
Abscess
Thrombosis
Fistulae
127
What are the most common sites for kidney stones?
Pelviureteric junction
pelvic brim
entry into the bladder
128
What types of renal stones are there?
Calcuim oxalate
Struvite
urate
cysteine
129
How do kidney stones present?
```
Pain - renal colic -loin to groin with nausea and vomitting
infection
haematuria
proteinuria
sterile pyuria
anuria
```
130
What is the gold standard of imaging for kidney stones?
Non contrast CT- used to see stones and rule out DDs
131
What is the management of kidney stones?
Analgesia - diclofenac and IV fluids and ABx if infection
<5mm in lower ureter- pass spontaneously with increased fluid
>5mm or pain not resolving - CCB or A blockers and most pass within 48 hours
132
What are the indications for urgent intervention?
Present infection and obstruction- percutaneous nephrectomy may be needed to relieve obstruction, urosepsis, intractable pain or vomitting, impending AKI, obstruction in solitary kidney and bilateral obstructing stones
133
What can be done in Calcium/ urate kidney stone management?
Thiazide duiretic- increase Ca reabsorption
| Urate stones - give allopurinol
134
What type of kidney stones are not seen on XR?
Urate
135
What are some predisposing factors for kidney stones?
Recurrent UTIs
Hypercalcuria, hyperparathyroidism, neoplasia, sarcoidosis, addisions, cushings, lithium, cystinuria, gout, renal tubular acidosis
any urinary tract abnormalities
136
What are the causes of retroperitoneal fibrosis?
Inflammatory aneurysms of the AAA
idopathic
malgnancy - typically lymphoma
137
What are the implications of retroperitoneal fibrosis?
Ureters get embedded in a dense fibrosis tissue resulting in progressive bilateral ureteric obstruction and dilation.
138
What is the typical patient for retroperitoneal fibrosis?
middle aged man with vague loin or back pain and increased BP
139
What will investigations typically show in a patient with retroperitoneal fibrosis?
increased urea and creatinine
increased ESR and CRP anaemia
USS - dilated ureters and hydronephrosis
CT/MRI - periaortic mass
140
What is the management of retroperitoneal fibrosis?
retrograde stent to relieve obstruction and uterolysis to dissect ureters out
may require immunosuppresion after procedure
141
What is the definition of an aneurysm?
Dilation of an artery greater than 1.5 times its normal diameter
142
What is the difference between a true and a pseudoaneurysm?
True involve all layers of the artery wall
| False involve a collection of blood in the outer layer only which communicates with the lumen
143
What are the causes of aneurysms?
```
Atheroma
Trauma
infection
connective tissue disorders
vasculitis - takaysukis
```
144
What are the complications of aneurysms?
```
Rupture
thrombosis
embolism
fistulae
pressure on other structures
```
145
What is the process of AAA screening?
All >65 year old males are invited for one off USS screening
146
What are the signs and symptoms of a ruptured AAA?
Intermittent or continuous abdo pain which can radiate to the back, iliac fossa or groin
collapse
expansile mass
147
When is elective surgery done in a AAA?
>=5.5cm or expanding at >1cm/year or symptomatic
148
What should we aim for the BP to be in a ruptured AAA and why?
SBP <100mmHg
| Permissive hypotension to avoid excess blood loss
149
What is dissection of the aorta?
Blood separates the aortic media
150
What are the signs and symptoms of a dissection?
Sudden shearing back chest and back pain
| As dissection progresses can result in hemiplegia, unequal arm pulses, BP or acute limb ischaemia, paraplegia and anuria
151
What are the classification for dissection and what does this mean for treatment?
De Backey and Stanford
A- surgery - involving the ascending aorta
B- non surgical management - doesnt involve the ascending aorta
152
What is the management for dissection?
Crossmatch 10 u
ECG and CXR
TOE
ITU and remain hypotensive
153
What is the pathophysiology behind PAD?
Atherosclerosis causing stenosis of the arteries
154
What are the symptoms of PAD?
Cramping pain in the calf, thigh or buttock after walking for a given distance and relieved by rest.
Ulceration, gangrene and foot pain at night are a sign of critical ischaemia
155
What is leriche syndrome?
Buttock claudication, wasting of the quads and impotence
156
What is fontaines classification?
1 - asymptomatic
2- intermittent claudication
3- ischaemic rest pain
4- ulceration and gangrene
157
What are the signs of PAD?
```
Absent pulses
cold white legs
atrophic skin
punched out painful ulcers
postural dependent colour changes
Buergers ankle - angle leg is raised to until it changes colour
```
158
What investigations should be done in a patient with PAD?
```
HbA1c
FBC- anaemia or polycythemia
U&Es - renal distress
lipids
ECG
ABPI
```
159
How should ABPI be interpretted?
Normal 1-1.2
PAD 0.5-0.9
critical ischaemia <0.5
may be falsely elevated in calcified vessels
160
What imaging should be done in those with PAD?
Colour duplex is first line
| if considering intervention - CT or MRI
161
Explain the treatment of PAD
Management of risk factors - prescribe an antiplatelet unless contraindicated
Management of claudication - supervised exercise programmes and vasoactive drugs
When conservative management fails
- percutaneous transluminal angioplasty- ballon inflation
- surgical reconstruction includes bypass surgery
- amputation
162
What is acute limb ischaemia?
May be due to thrombus, embolus, graft/angioplasty occulsion or trauma
surgical emergancy- 4-6 hours to save the limb
163
What are the signs and symptoms of acute limb ischaemia?
```
Pale
Pulseless
Painful
Perishingly cold
paraylsed
paraesthetic
```
mottled indicates that the change irreversible
164
What is the management of acute limb ischaemia?
Open surgery or angioplasty
if in doubt about the diagnosis do arteriography
embolus - fogarty catheter
Thrombus - thrombolysis
Anticoagulate with heparin after
monitor for signs of compartment syndrome
165
What are varicose veins?
tourtous, dilated long veins that are visible to the naked eye
166
What is the pathophysiology behind varicose veins?
blood from the superficial system passes to the deep venous system via perforators and at the saphenofemoral and saphenopopliteal junctions. Valves usually prevent back flow but if these become incompetent we see back flow and therefore venous hypertension and dilation of the superficial veins
167
What are the risk factors for varicose veins?
Prolonged standing, obesity, pregnancy, family history, COCP
168
what are the symptoms of the varicose veins?
Pain, cramp tingling, heaviness and restless legs
169
What are the signs of varicose veins?
Haemosiderin deposition
Atrophie blanchie- white scarring at the site of previous ulcers
Swelling
Lipodermosclerosis - skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis
Ezcema
Gaiter ulcers
Scars
170
What are the treatments for varicose veins?
Treat any underlying cause
Education - avoid prolonged standing and elevate legs whenever posssible
Endovascular treatment - radiofrequency abalation, endovenous abalation, injection sclerotherapy,
surgery - ligation, stripping
171
What is a saphena varix?
Dilation of the saphenous vein at its confluence with the femoral vein- may be mistaken for a femoral/inguinal hernia but on examination will have blue tinge
172
What is gangrene?
death of tissue from poor vascular supply and sign of critical ischaemia
Dry gangrene - no infection - will have line of demarkation
wet gangrene - tissue death and infection
Gas gangrene - subset of necrozing myositis caused by clostridium species
173
What are the different types of ulcers?>
Arterial
Venous
Mixed
neuropathic
174
What determines whether compression bandage can be used?
ABPI >.8
175
What is a Marjolin ulcer?
Long standing ulcer that develops a SCC in the center
176
What is granulation tissue in an ulcer and what does it signify?
Deep pink gel -like matrix contained within a fibrinous network and evidence of healing
