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Flashcards in Surgery & Vascular Deck (115):
1

Drugs to stop before surgery

- Clopidogrel 7d before
- Warfarin 5d before (if high risk - bridging LMWH and stop 12h preop) restart LMWH 6h post op and warfarin next day
- OCP/ HRT 4 weeks before and restart 2 weeks after
- oral hypoglycaemia - stop from day of surgery until eat again ( if cant eat start sliding scale)
- Insulin - sliding scale (up until eat again)

2

Pre-op investigations

Bloods
- +/- crossmatch
CXR if symptoms or > 65
ECG if HTN/ >55
MRSA swabs

3

When should nutrition be stopped before surgery

>2 hours for clear fluids
>6 hours for solid food

4

When should DVT prophylaxis be given

- All - TED stockings

Low risk/ neck surgery - early mobilisation
Mod risk - + 20mg dalteparin
High risk + 40mg dalteparin + intermittent compressino boots peri-op

5

ASA grades

1. Normally healthy
2. Mild systemic disease
3. Severe systemic disease that limits activity
4. Systemic disease which is a constant threat to life
5. Moribund: not expected to survive 24h even with op

6

Mallampati score

1) complete visualisation of soft palate
2) complete visualisation of uvula
3) visualisation of uvula base
4) Can'e see soft palate

7

Pre-medication for anaesthesia

 Anxiolytics and Amnesia: e.g. temazepam
 Analgesics: e.g. opioids, paracetamol, NSAIDs
 Anti-emetics: e.g. ondansetron 4mg / metoclop 10mg
 Antacids: e.g. lansoprazole
 Anti-sialogue e.g. glycopyrolate (↓ secretions)
 Antibiotics

8

3 principals of anaesthesia

- Muscle relaxation
- Hypnosis
- Analgesia

9

Main drugs used in anaesthesia

Induction - propofol
Muscle relaxation - suxamethonium
Airway control - ET tube/LMA
Maintenance - N20/oxygen mix e.g. halothane
Reversal - neostigmine and glycopyrronium bromide

10

Complications of anaesthesia

Propofol - Cardiorespiratory depression
Intubation - Oro-pharyngeal injury/ Oesophageal intubation
Loss of pain sensation - Urinary retention/ Pressure necrosis/ Nerve palsies
Loss of muscle power - Corneal abrasion
 No cough → atelectasis + pneumonia
Malignant Hyperpyrexia - Rapid rise in temperature + masseter spasm
 Rx: dantrolene + cooling
Anaphylaxis

11

Analgesia pain ladder

1) Paracetamol and NSAIDS (SE - IGRAB - interact - warfarin, Gastric ulcer, Renal Impairement, Asthma, Bleeding)
2) Weak opiod + non-opiod
- codiene, tramadol
3) strong opiod + non-opiod
- morphone, oxycodone, fentayl

12

Positives and negatives of PCA

+ve
- analgesia tailored to pt requirements
- reduced risk of overdose
- can record easily
- reduce staff workloads
- reduce need for IM injections
-ve
- can stop pt mobilising
- not appropriate if low dexterity/ dementia
- initial equipment expensive
- pt has to understand

13

+ve and -ve of syringe drivers

+ve
- avoid large swings in pain
- reduce staff workload
- good if pt ventilated
- useful if low dexterity
-ve
- only get right rate after initial error

14

What is spinal anaesthesia and complications

- anaesthesia into sub-arachnoid space, to affect the spinal roots passing through

complications - total spinal block; headache; urinary retention; permanent neurological damage

15

What is epidural anaesthesia and its complications

- Anaesthesia into extradural space )need firmly into ligamentum flavum - loss of resistance)
compoications
- headache
- vesel puncture
- apnoea
- LOC
- hypoventilation
- marked hypotension
- epidural haemotoma
- nerve- root damage
- patchy/ unil;ateral block

16

CI for epidural anaesthesia

Anti-coagulated
local sepsis
shock/ hgypovolaemia
raised ICP
Uncooperate pt
MS/AS

Relative CI - neurological disease, IHD, previous deformity of spins/surgery, bowel perforation

17

Pre operative optimisation

Aggressive physiological optimisation
 Hydration
 BP (↑ / ↓)
 Anaemia
 DM
 Co-morbidities
 Smoking cessation: ≥4wks before surgery

18

Post operative enhanced recovery

 Aggressive Rx of pain and nausea
 Early mobilisation and physiotherapy
 Early resumption of oral intake (inc. carb drinks)
 Early discontinuation of IV fluids
 Remove drains and urinary catheters ASAP

19

Surgical complications

Immediate (<24h)
 Intubation → oropharyngeal trauma
 Surgical trauma to local structures
 Primary or reactive haemorrhage

Early (1d-1mo)
 Secondary haemorrhage
 VTE
 Urinary retention
 Atelectasis and pneumonia
 Wound infection and dehiscence
 Antibiotic association colitis (AAC)

Late (>1mo)
 Scarring
 Neuropathy
 Failure or recurrence

20

Causes and risk factors for post op urinary retention

Causes
 Drugs: opioids, epidural/spinal, anti-AChM
 Pain: sympathetic activation → sphincter contraction
 Psychogenic: hospital environment

Risk Factors
 Male
 ↑ age
 Neuropathy: e.g. DM, EtOH
 BPH
 Surgery type: hernia and anorectal

21

Signs and Treatment of post op urinary retention

Signs
- reduced urine output
- sensation of needing to void
- suprapubic mass which is dull to percuess

- bladder scan for residual volume

Mx
 Privacy  Ambulation
 Void to running taps or in hot bath  Analgesia

 Catheterise ± gent 2.5mg/kg IV stat
 TWOC = Trial w/o Catheter

 If failed, may be sent home c¯ silicone catheter
and urology outpt. f/up

22

Causes, presentation and mx of Pulmonary Atelectasis

- after every nearly every GA
 Mucus plugging + absorption of distal air → collapse

Causes
 Pre-op smoking
 Anaesthetics ↑ mucus production ↓ mucociliary
clearance
 Pain inhibits respiratory excursion and cough

Presentation
 w/i first 48hrs
 Mild pyrexia
 Dyspnoea
 Dull bases c¯ ↓AE
Mx
 Good analgesia to aid coughing
 Chest physiotherapy

23

Operative classification of wounds

 Clean: incise uninfected skin w/o opening viscus
 Clean/Cont: intra-op breach of viscus (not colon)
 Contaminated: breach of viscus + spillage or opening of
colon
 Dirty: site already contaminated – faeces, pus, trauma

24

Risk factors for post-op wound infections

Pre-operative
 ↑ Age
 Comorbidities: e.g. DM
 Pre-existing infection: e.g. appendix perforation
 Pt. colonisation: e.g. nasal MRSA
 Malnourished/ obese
Operative
 Op classification and wound infection risk
 Duration
 Technical: pre-op Abx, asepsis

Post-operative
 Contamination of wound from staff

25

Mx and prevention of post-op wound infections

 Regular wound dressing
- clear for 48 hour after surgery
- removed clips/ sutrues
 Abx
 Abscess drainage

Prevention
- shower before surgery
- electric clippers
- abx?
- sterile technique

26

Risk factors for wound dehiscence

Pre-Operative Factors
 ↑ age
 Smoking
 Obesity, malnutrition, cachexia
 Comorbs: e.g. BM, uraemia, chronic cough, Ca
 Drugs: steroids, chemo, radio

Operative Factors
 Length and orientation of incision
 Closure technique
 Suture material

Post-operative Factors
 ↑ IAP: e.g. prolonged ileus → distension
 Infection
 Haematoma / seroma formation

27

Mx of wound dehiscence

 Replace abdo contents and cover c¯ sterile soaked gauze
 IV Abx: cef+met
 Opioid analgesia
 Call senior and arrange theatre
 Repair in theatre
- Wash bowel
- Debride wound edges
-Close c¯ deep non-absorbable sutures

28

Complications of cholecystectomys

 Conversion to open: 5%
 CBD injury: 0.3%
 Bile leak
 Retained stones (needing ERCP)
 Fat intolerance / loose stools

29

Complications of inguinal hernia repairs

Early
 Haematoma / seroma formation: 10%
 Intra-abdominal injury (lap)
 Infection: 1%
 Urinary retention

Late
 Recurrence (<2%)
 Ischaemic orchitis: 0l5%
 Chronic groin pain / paraesthesia: 5%

30

Complications of appendicectomy

 Abscess formation
 Fallopian tube trauma
 Right hemicolectomy (e.g. for carcinoid, caecal
necrosis)

31

Complications of colonic surgery

Early
 Ileus
 AAC
 Anastomotic leak
 Enterocutaneous fistulae
 Abdominal or pelvic abscess
Late
 Adhesions → obstruction
 Incisional hernia

32

Complications of anorectal surgery

 Anal incontinence
 Stenosis
 Anal fissure

33

Complications of small bowel surgery

Short gut syndrome

34

Complications of splenectomy

Gastric dilatation (2O gastric ileus) - Prevent c¯ NGT
 Thrombocytosis → VTE
 Infection: encapsulated organisms

35

Complications or arterial and aortic surgery

Arterial Surgery
 Thrombosis and embolization
 Anastomotic leak
 Graft infection

Aortic Surgery
 Gut ischaemia
 Renal failure
 Aorto-enteric fistula
 Anterior spinal syndrome (paraplegia)
 Emboli → distal ischaemia (trash foot)

36

Causes of post-op pyrexia

WIND - pulmonary atelectasis / pneumonia
WATER - UTI (3-5d)
WALK - VTE (5-10d)
WOUND - cellulitis (early) infection or anastomotic leak(5d +)
WORRY ABOUT DRUGS (7d +)
- drug reaction

37

Causes of post-op pneumonia and management

 Anaesthesia → atelectasis
 Pain → ↓ cough
 Surgery → immunosuppression

Rx
 Chest physio: encouraging coughing
 Good analgesia
 Abx

38

Presentation, locations and Rx of a post-op collection

 Malaise
 Swinging fever, rigors
 Localised peritonitis
 Shoulder tip pain (if subphrenic)
Locations
 Pelvic: 4-10d post-op
 Subphrenic: 7-21d post-op
 Paracolic gutters
 Lesser sac
 Hepatorenal recess
 Small bowel
Rx
 Abx
 Drainage / washout

39

Causative organisms of post-op cellulitis

Acute infection of the subcutaneous connective tissue

β-haemolytic Streps + staph. aureus

40

Presentation and Rx of post-op cellulitis

 Pain, swelling, erythema and warmth
 Systemic upset
 ± lymphadenopathy

 ABx - fluclox

41

Virchow's triad

Hypercoagulability
- Surgery → ↑ plats and ↑ fibrinogen + Dehydration
Stasis
- surgery/ immobility/ obesity
Endothelial damage
- esp. pelvic veins/ Previous VTE

42

Signs of DVT

- Calf warmth/ tenderness/ swelling/ erythema
- Mild fever
- Pitting oedema

43

Risk factors for DVT

- ↑ Age
- Pregnancy
- Synthetic Oestrogen
- Trauma
- Surgery (especially pelvic/orthopaedic)
- Past DVT
- Cancer
- Obesity
- Immobility
- Thrombophilia
- Long-distance travel (dehydration, immobilisation, ↓ O2 tension, prolonged sitting)

44

Differentials for DVT

- cellulitis
- Ruptured bakers cyst

45

Dx of DVT

2-Level DVT Wells Score
Cancer, immobility, local tenderness, leg swollen, calf swelling >3cm, pitting oedema. Collateral superficial veins., previous DVT

≤ 1 – DVT unlikely
Perform D-Dimer.
- If -ve, DVT excluded
- If +ve, proceed to USS (if USS -ve, DVT excluded; if +ve treat as DVT)

≥ 2  DVT likely
Do D-Dimer & USS.
- If both -ve DVT excluded.
- If USS +ve – treat DVT.
- If USS -ve and D-Dimer +ve – repeat USS in 1 week.

46

Rx of DVT

 Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC
 Start warfarin
 Stop LMWH when INR 2.5

Duration
 Below knee: 6-12wks
 Above knee: 3-6mo

Graduated Compression Stockings

47

Preventing DVTs

Pre-Op
 TED stockings
 Aggressive optimisation: esp. hydration
 Stop OCP 4wks pre-op

Intra-Op
 Minimise length of surgery
 Use minimal access surgery where possible
 Intermittent pneumatic compression boots

Post-Op
 LMWH
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration

48

Factors which increase risk of post-op N&V

Patient
- female
- non-smoker
- young
- hx motion sickness
- hx migraines
- anxiety
Surgical
- abdo/gynae procedure (obstruction/ileus)
- cholecystectomy
- thyroid
- ophthalmology
Anaesthetic
- NO
- Opioid pre-op
- Long duration

49

Consequences of PONV

- electrolyte imbalance
- hypovolaemia
- disrupt surgical site

50

Where is the vomiting centre and what are the NT involved

- Medulla Oblongata
- involes histamine, Dopamine and acetylcholine

51

Treatment of PONV

- metoclopramide (Da I)
- Ondansetron (5HT I)
- Hyoscine (Anti-Ach)

52

Causes of post-op dyspnoae/ hypoxia

 Previous lung disease
 Atelectasis, aspiration, pneumonia
 LVF
 PE
 Pneumothorax (e.g. due to CVP line insertion)
 Pain → hypoventilation

- CXR and ECG

53

Causes and Rx of reduced urine output post-op

Post-renal
 Blocked / malsited catheter
 Acute urinary retention
Pre-renal: hypovolaemia
Renal: NSAIDs, gentamicin


- Stop responsible drugs, Assess fluid status, Inspect drips, drains, stomas, CVP
 Flush - 50ml NS and aspirate back
 Fluid challenge

54

Causes and Mx of post-op hyponatraemia

 S(I)ADH: pain, nausea, opioids, stress
 Over administration of IV fluids

 Correct slowly
 Acute: 1mM/h
 Chronic:15mM/d

55

Causes of post-op hypotension

CHOD
Cardiogenic
 MI
 Fluid overload
Hypovolaemia
 Inadequate replacement of fluid losses
 Haemorrhage
Obstructive
 PE
Distributive
 Sepsis
 Neurogenic shock

56

Mx of post-op hypotension

 Tilt bed head down, give O2
 Assess fluid status
 Hypovolaemia → fluid challenge - 250-500ml colloid over 15-30min
 Haemorrhage → return to theatre
 Sepsis → fluid challenge, start Abx
 Overload → frusemide
 Neurogenic → NA infusion

57

Causes and Mx of post-op hypertension

 Pain
 Urinary retention
 Previous HTN

Mx - Rx cause
 May use labetalol 50mg IV every 5min (200mg max)

58

Causes of post-op confusional state

 Drugs: opiates, sedatives, L-DOPA
 Eyes, ears and other sensory deficits
 Low O2 states: MI, stroke, PE
 Infection
 Retention: stool or urine
 Ictal
 Under- hydration / -nutrition
 Metabolic: Na, AKI, glucose, EtOH withdrawal

59

Factors to consider when prescribing fluids

- Resuscitation
- Routine Maintenance
- Replacement (v&d&sweat)
- Redistribution
- Reassess every 24h

60

Different types of IV fluid

Crystalloid
- 0.9% NaCl
- 5% dextrose
- Dextrose saline (0.18%NS and 4% dextrose)
- Hartmann's (Na, Cl, K, Ca, Lactate)

Colloid
- Blood (risk anaphylaxis)

61

Examination of fluid status

IV volume
 CRT
 HR
 BP lying and standing
 JVP
Tissue perfusion
 Skin turgor
 Oedema: ankle, pulmonary, ascites
 Mucus membranes
End-organ
 UO, ↑U+Cr
 Consciousness
 Lactate

62

Feeding hierachy

Enteral
Oral nutritional supplements - If unable to eat sufficient calories (ONS)
NGT/NJ - ↓ calories orally or dysfunctional swallow
SE – gastric erosions
(NJ if risk of pul regurgitation)
PEG/RIG - oesophagus blocked/dysfunctional
- med-long term
Jejunostomy - stomach inaccessible/ outflow obstruction

Parental
- jejunum inaccessible or intestinal failure or obstructed gut
TPN IV – very thrombogenic

63

Positives and negatives of enteral feeding

+ve
- less invasive
- keeps gut bacteria working
-ve
- nasal trauma tube blockage
- diarrhoea, electrolyte imbalance, aspiration, refeeding syndrome

64

Indications for TPN

 Prolonged obstruction or ileus (>7d)
 High output fistula
 Short bowel syndrome
 Severe Crohn’s
 Severe malnutrition
 Severe pancreatitis
 Unable to swallow: e.g. oesophageal Ca

65

Complications of TPN

Line-related
 Pneumothorax /haemothorax
 Cardiac arrhythmia
 Line sepsis
 Central venous thrombosis → PE or SVCO

Feed-related
 Villous atrophy of GIT
 Electrolyte disturbances
 Refeeding syndrome
 Hypercapnoea from excessive CO2 production
 Hyperglycaemia and reactive hypoglycaemia
 Line sepsis: ↑ risk c¯ TPN
 Vitamin and mineral deficiencies

66

What is refeeding syndrome and complications

↓ carbs → catabolic state c¯ ↓insulin, fat and protein
catabolism and depletion of intracellular PO4

Refeeding → ↑ insulin in response to carbs and ↑
cellular PO4 uptake → hypophosphataemia
 Rhabdomyolysis
 Respiratory insufficiency
 Arrhythmias
 Shock
 Seizures

67

Patients at risk of refeeding syndrome

 Malignancy
 Anorexia nervosa
 Alcoholism
 GI surgery
 Starvation

68

Pathogenesis of atherosclerosis

• Triggered by injury (HTN/ ↑ lipids)
• Lipoproteins oxidised - taken up by macrophages =
foam cells
• Release of cytokines → accumulation fat and smooth
muscle proliferation
• Plaque formation

69

Risk factors for atherosclerosis

Modifiable
 Smoking
 BP
 DM control
 Hyperlipidaemia
 ↓ exercise

Non-modifiable
 FH and PMH
 Male
 ↑ age
 Genetic

70

Presentation of intermittent claudication

 Cramping pain after walking a fixed distance
 Pain rapidly relieved by rest
 Calf pain = superficial femoral disease (commonest)
 Buttock pain = iliac disease (internal or common)

71

Presentation of critical limb ischaemia

Rest pain
 Especially @ night
 Usually felt in the foot
 Pt. hangs foot out of bed
 Due to ↓ CO and loss of gravity help
Ulceration
Gangrene

72

Leriche’s Syndrome presentation

Atherosclerotic occlusion of abdominal aorta and iliacs

 Buttock claudication and wasting
 Erectile dysfunction
 Absent femoral pulses

73

Signs of chronic limb ischaemia

 Pulses: pulses and ↑ CRT (norm ≤2sec)
 Ulcers: painful, punched-out, on pressure points
 Nail dystrophy / Onycholysis
 Skin: cold, white, atrophy, absent hair
 Venous guttering
 Muscle atrophy
 ↓ Buerger’s Angle
- ≥90: normal
- 20-30: ischaemia
- <20: severe ischaemia
 +ve Buerger’s Sign
 Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries

74

Fontaine classification of chronic limb ischaemia

1. Asympto (subclinical)
2. Intermittent claudication
a. >200m
b. <200m
3. Ischaemic rest pain
4. Ulceration / gangrene

75

Ix for chronic limb ischaemia

ABPI (ankle/brachial pressure index) - diagnosis & quantify severity.
 Normal > 1.1
Doppler USS - Assess the severity and anatomical location of any occlusion.

CT angiography or MR angiography (MRA).

CV risk assessment - BP, glucose, lipid profile and ECG.

< 50 yrs without significant risk factors - thrombophilia screen and homocysteine levels checked.

76

Mx of chronic limb ischaemia

CV risk modification – 78%
• Lifestyle advice (smoking cessation, regular exercise, weight reduction)
o improve walking technique to optimise collateral blood distribution
• Statin
• Aspirin or clopidogrel
• Optimise diabetes control
- Analgesia

Surgical
- Indications
 V. short claudication distance (e.g. <100m)
 Symptoms greatly affecting QoL
 Development of rest pain
+ Conservative failed

 Angioplasty with stenting – single occluded region
 Endarterectomy: core-out atheromatous plaque
 Bypass grafting – diffuse disease
 Amputation – unsuitable for revascularisation with ischaemia causing incurable symptoms or gangrene --> sepsis

77

Causes of acute limb ischameia

 Thrombosis in situ (60%)
 Embolism (30%) - AF/ Valve disease
- Iatrogenic from angioplasty / surgery
- Cholesterol in long bone #
- Paradoxical (venous via PFO)
 Graft / stent occlusion
 Trauma
 Aortic dissection

78

Presentation of acute limb ischaemia

 Pale
 Pulseless
 Perishingly cold
 Painful
 Paraesthesia
 Paralysis

79

Thrombosis v embolus presentation of acute limb ischaemia

Thrombosis
Hrs-days
Less severe ischaemia - (collaterals)
Claudication Hx
Contralat pulses Absent
Dx Angiography
Rx Thrombolysis or Bypass surgery

Embolus
Suddenly
Profound ischaemia
Embolic source (AF)
Clinical Dx
Present contralat pulse
Rx - embolectomy + Warfarin

80

Mx of acute limb ischaemia

 NBM
 Rehydration: IV fluids
 Analgesia: morphine + metoclopramide
 Abx: e.g co-omox if signs of infection
 Unfractionated heparin IVI
 Complete occlusion?
- Yes: urgent surgery: embolectomy (using balloon catheter) or bypass
Thrombolysis oif unsuccessful
- No: angiogram + observe for deterioration

Unsuccessful - emergency reconstruction/ amputation

81

Rx before embloectomy and complications post- embolectomy

Rx
Anticoagulate: heparin IVI → warfarin
 ID embolic source: ECG, echo, US aorta, fem and pop

Complications
> Reperfusion injury
 Local swelling → compartment syndrome
 Acidosis and arrhythmia 2O to ↑K
 ARDS
 GI oedema → endotoxic shock
Chronic pain syndromes

82

Classifications of anerysms

Abnormal dilatation of a blood vessel > 50% of its
normal diameter.

 True Aneurysm
involving all layers of
the wall and is >50% of its normal diameter

 False Aneurysm
Collection of blood around a vessel wall that
communicates c¯ the vessel lumen.
 Usually iatrogenic: puncture, cannulation

Dissection
 Vessel dilatation caused by blood splaying apart
the media to form a channel w/i the vessel wall.

83

Causes of aneurysms

Congenital
 ADPKD → Berry aneurysms
 Marfan’s, Ehlers-Danlos
Acquired
 Atherosclerosis
 Trauma: e.g. penetrating
 Inflammatory: Takayasu’s aortitis, HSP
 Infection - Tertiary syphilis

84

Complications of aneurysms

 Rupture
 Thrombosis
 Distal embolization
 Pressure: DVT, oesophagus, nutcracker syndrome
 Fistula (IVC, intestine)

85

Presentation and Mx of a popliteal aneurysm

 Very easily palpable popliteal pulse
 50% bilateral
 Rupture is relatively rare
 Thrombosis and distal embolism is main complication → acute limb ischaemia

Mx
 Acute: embolectomy or fem-distal bypass
 Stable: elective grafting + tie off vessel

86

Presentation of AAA

Dilatation of the abdominal aorta ≥3cm
 90% infrarenal; 30% involve the iliac arteries

 Usually asympto: discovered incidentally
 May → back pain or umbilical pain radiating to groin
 Acute limb ischaemia
 Blue toe syndrome: distal embolisation
 Acute rupture

87

Examination features of AAA

 Expansile mass just above the umbilicus
 Bruits may be heard
 Tenderness + shock suggests rupture

88

Ix of AAA

CT / MRI: gold-standard
AXR: calcification
Abdo US: screening and monitoring
 Angiography
- delineate relationship of renal arteries

89

Mx of AAA


 Manage CV risk factors: esp. BP
3.0-4.4cm: yearly Duplex USS & 5.0-5.4cm: 3-m Duplex USS

Surgical
- before it ruptures.
 Indications
 Symptomatic (back pain = imminent rupture)
 Diameter >5.5cm
 Rapidly expanding: >1cm/yr
 Causing complications: e.g. emboli
 Open or EVAR

Risks - EVAR - endovascular leak, graft infection
OPEN - AKI when clamp aorta

Screening - one off at 65

90

Presentation of AAA rupture

 Sudden onset severe abdominal pain - Radiates to back or flanks (don’t dismiss as colic)
 Hypotension/; Collapse → shock
 Expansile abdominal mass

91

Factors which increase risk of AAA rupture

 ↑BP
 Smoker
 Female
 Strong FH

92

Differentials of AAA rupture

- renal colic
- diverticulitis
- IBD/IBS
- GI haemorrhage
- appendicitis
- ovarian torsion/rupture

93

Complications of AAA

Rupture
retroperitoneal leak
embolisation
aortaduodenal fistrula
infection

94

Management of ruptured AAA

 High flow O2
 2 x large bore cannulae in each ACF
- Give fluid if shocked but keep SBP <100mmHg
- Give O- blood if desperate
 Blood: FBC, U+E, clotting, amylase, xmatch 10u
 Instigate the major haemorrhage protocol
 Call vascular surgeon, anaesthetist and warn theatre
 Analgesia
 Abx prophylaxis: cef + met
 Urinary catheter + CVP line
 If stable + Dx uncertain: US or CT may be feasible (to see if suitable for EVAR)
 Take to theatre: clamp neck, insert dacron graft

95

Presentation of thoracic aortic dissection

 Sudden onset, tearing chest pain
-Radiates through to the back
- Tachycardia and hypertension
 Distal propagation → sequential occlusion of branches
- Left hemiplegia
- Unequal arm pulses and BP
- Paraplegia (anterior spinal A.)
- Anuria
 Proximal propagation
- AR/ Tamponade
 Rupture into pericardial, pleural or peritoneal cavities

96

Classification of aortic dissection

Type A: Proximal
 70%
 Involves ascending aorta ± descending
 Higher mortality due to probable cardiac involvement
 Usually require surgery

Type B: Distal
 30%
 Involves descending aorta only: distal to L SC artery
 Usually best managed conservatively

97

Differentials of aortic dissection

MI
PE
Pericarditis
MSK

98

Mx of aortic dissection

- Resuscitate
- Investigate
 Bloods: x-match 10u, FBC, U+E, clotting, amylase
 ECG: 20% show ischaemia; exclude MI
 Imaging
 CXR
 CT/MRI: not if haemodynamically unstable
 TOE: can be used if haemodynamically unstable

Treat
 Analgesia
 ↓SBP
- Labetalol/ esmolol (short t½)
 Keep SBP 100-110mmHg
 Type A: open repair
 Type B: conservative initially

99

Definition and pathophysiology of varicose veins

Tortuous, dilated veins of the superficial venous system

 One-way flow from sup → deep maintained by valves
 Valve failure → ↑ pressure in sup veins → varicosity
- SFJ: 3cm below and 3cm lateral to pubic tubercle
- SPJ: popliteal fossa

100

Causes of varicose veins

Primary
 Idiopathic (congenitally weak valves)
 Prolonged standing
 Pregnancy
 Obesity
 OCP
 FH

Secondary
 Valve destruction → reflux: DVT, thrombophlebitis
 Obstruction: DVT, foetus, pelvic mass (uterine/ovarian)
 Constipation
 AV malformation
 Overactive pumps (e.g. cyclists)

101

Symptoms of varicose veins

 Cosmetic defect
 Pain, cramping, heaviness
 Tingling
 Bleeding: may be severe
 Swelling

102

Signs of varicose veins

Skin changes
 Venous stars
 Haemosiderin deposition
 Venous eczema
 Lipodermatosclerosis (paniculitis)
 Atrophie blanche (scar tissue)
Ulcers: medial malleolus / gaiter area
Oedema
Thrombophlebitis

103

Ix of varicose veins

Duplex ultrasonography
 Anatomy
 Presence of incompetence
 Caused by obstruction or reflux

104

Referral criteria for varicose veins

 Bleeding
 Pain
 Ulceration
 Superficial thrombophlebitis
 Severe impact on QoL

105

Mx of varicose veins

 Lose weight
 Relieve constipation
 Avoid prolonged standing
 Regular walks
 Class II Graduated Compression Stockings
 Maintain hydration - emollients
 Treat ulcers rapidly

Surgery
- Injection sclerotherapy
- radiofrequency ablation
- SSV ligation

106

Complications of varicose vein surgery

 Haematoma (esp. groin)
 Wound sepsis
 Damage to cutaneous nerve (e.g. long saphenous)
 Superficial thrombophlebitis
 DVT
 Recurrence: may approach 50%

107

Causes of leg ulcers

 Venous: commonest
 Arterial: large or small vessel
 Neuropathic: EtOH, DM
 Traumatic: e.g. pressure
 Systemic disease: e.g. pyoderma gangrenosum
 Neoplastic: SCC

108

Presentation of venous ulcers

 +/- Pain, sloping, shallow ulcers with irregular borders
 Usually on medial malleolus: “gaiter area”
 Assoc. c¯ haemosiderin deposits, lipodermatosclerosis and oedema
 RFs: venous insufficiency, varicosities, DVT, obesity

109

Presentaion of arterial ulcers

Arterial: 2%
 Hx of vasculopathy and risk factors
 Painful (esp at night), deep, punched out lesions on a necrotic base
 Occur @ pressure points
 Heal
 Tips of. and between, toes
 Metatarsal heads (esp. 5th)
 Other signs of chronic leg ischaemia - cold, weak peripheral pulses, shiny pale skin, loss of hair
ABPI <0.8

110

Features of neuropathic ulcers

Painless c¯ insensate surrounding skin
 Warm foot c¯ good pulses
hx DM, Vit B def

111

Complications of ulcers

 Osteomyelitis
 Development of SCC in the ulcer (Marjolin’s ulcer)

112

Mx of venous ulcers

Refer to leg ulcer community clinic
 Graduated compression stockings
 Venous surgery
 Optimise risk factors: nutrition, smoking

 Analgesia
 Bed Rest + Elevate leg
 4 layer graded compression bandage (if ABPI >0.8)

113

Differentials of bilateral leg swelling

↑ Venous Pressure
- RHF
- Venous insufficiency
- Drugs: e.g. nifedipine
↓ Oncotic Pressure
- Nephrotic syndrome
- Hepatic failure
- Protein losing enteropathy
Lymphoedema
Myxoedema
- Hyper- / hypo-thyroidism

114

Differentials of unilateral leg swelling

Venous insufficiency
DVT
Infection or inflammation
Lymphoedema

115

Causes of hepatomegaly, splenomegaly and hepatosplenomegaly

Hepatomegaly
- cirrhosis
- hepatitis
- NAFLD
- malignancy

Splenomegaly
- Splenic/hepatic vein thrombosis
- thalassaemia
- malaria
- CML/ Myelofibrosis
- HIV
- Cirrhosis

Hepatosplenomegaly
- CLD and portal HTN
- Hepatitis virus and CMV
- Malaria
- Sarcoidosis
- Leukaemia