VASCULAR/HAEM Flashcards
(95 cards)
1
Q
What are some causes of AAA?
A
- atheroma
- trauma
- infection
- CTDs
- inflammation e.g. Takayasu’s
2
Q
What screening is in place for AAA? Explain the results
A
Offered as one off to all men over 65 - USS
- SMALL (3-4.4cm)
- no treatment, annual check-up + lifestyle advice - MEDIUM (4.5 - 5.4cm)
- no treatment, 3-monthly check up, lifestyle advice - HIGH (5.5cm or greater)
- high risk of bursting = elective EVAR required
3
Q
How do you manage a ruptured AAA?
A
If haemodynamically stable, use CT to diagnose rupture
- Inform vascular surgeon + anaesthetist
- Perform: ECG, FBC, Amylase, Crossmatch, catheterise
- IV access - 2 large bore cannulae
- Treat shock with O- blood
- keep sBP below 100 to avoid rupturing contained leak - Give prophylactic Abx - cefuroxime + metronidazole
- Immediate transfer to theatre from A+E
4
Q
What are some causes of microcytic anaemia? (TAILS)
A
T - Thalassaemia A - Anaemia of chronic disease I - Iron deficiency anaemia (= chronic blood loss, malabsorption, poor intake) L - Lead poisoning S - Sideroblastic anaemia
5
Q
What are some causes of normocytic anaemia?
A
A - Acute blood loss A - Anaemia of chronic disease A - Aplastic anaemia H - Haemolytic anaemia H - Hypothyroidism
6
Q
What are (i) megaloblastic + (ii) normoblastic causes of macrocytic anaemia?
A
(i) B12 or folate deficiency
(ii) alcohol excess
- reticulocytosis
- hypothyroidism
- liver disease
- drugs (azathioprine, phenytoin)
- marrow infiltration
- myelodysplastic syndromes
7
Q
What do iron studies show in IDA?
A
FERRITIN - low, if normal then there may be an inflammatory process going on at same time TIBC - increased TRANSFERRIN SATURATION - increased
8
Q
What is the 2ww pathway for patients with IDA?
A
All aged over 60 with IDA
Aged over 50 with rectal bleeding + IDA
9
Q
If there is both B12 + folate deficiency, how do you treat?
A
Treat B12 FIRST
- treating pts with folic acid when they have B12 deficiency can lead to subacute combined degeneration of the cord
10
Q
What test is specific for pernicious anaemia?
A
Intrinsic factor antibody
11
Q
How is B12 deficiency treated?
A
1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months
12
Q
What are the inherited causes of haemolytic anaemia?
A
- Hereditary spherocytosis
- Hereditary elliptocytosis
- Thalassaemia
- Sickle cell anaemia
- G6PD
13
Q
What are the acquired causes of haemolytic anaemia?
A
AIHA
- alloimmune haemolytic anaemia
- paroxysmal nocturnal haemoglobinuria
- microangiopathic haemolytis anaemia
- prosthetic heart valve related haemolysis
14
Q
How does hereditary spherocytosis tend to present?
A
Jaundice, gallstones, splenomegaly
- aplastic crisis in presence of parovirus
15
Q
How is hereditary spherocytosis managed?
A
Folate supplementation + splenectomy
- cholecystectomy may be required
16
Q
How does G6PD tend to present? What are some triggers?
A
Jaundice, gallstones, anaemia, splenomegaly
- Heinz bodies on blood film
- triggers = broad beans, anti-malarials, sulfalazine
17
Q
How is AIHA managed?
A
- Blood transfusions
- Prednisolone
- Rituximab
- Splenectomy
18
Q
How do you confirm diagnosis of sickle cell disease?
A
Hb electrophoresis
19
Q
What are some complications of sickle cell disease?
A
- anaemia
- increased risk of infection
- stroke, AVN in large joints
- pulmonary HTN
- priapism (painful + persistent erection)
- CKD
- sickle cell crisis
- acute chest syndrome
20
Q
What is the general management for sickle cell patients?
A
- Avoid dehydration, keep warm + other triggers
- Vaccines up to date
- Abx prophylaxis = phenoxymethylpenicillin
- Hydroxycarbamide
- Blood transfusions for severe anaemia
- Bone marrow transplant can be curative
21
Q
Describe thrombotic/vaso-occlusive sickle crisis.
A
Painful crisis
- precipitated by infection, dehydration, deoxygenation
- RBCs clog capillaries causing distal ischaemia
- can cause priapism in men
22
Q
Describe splenic sequestration crisis in sickle cell.
A
RBCs block flow to spleen
- large + painful spleen
- medical emergency use blood transfusions + fluid resus
- splenectomy is definitive treatment
23
Q
Describe aplastic crisis in sickle cell.
A
Caused by parovirus B19
- sudden drop in Hb as temp loss of creation of new RBCs
24
Q
Describe acute chest syndrome in sickle cell.
A
Presents with dyspnoea, chest pain, pulmonary infiltrates on CXR, low pO2
- medical emergency
25
How is beta-thalassaemia managed?
1. Regular transfusions
- monitor serum ferritin levels
2. Iron chelation - prevent/treat iron overload
3. Splenectomy
4. Bone marrow transplant can potentially be curative
26
What are some differentials for abnormal/prolonged bleeding?
- thrombocytopenia (low platelets)
- haemophilia A or B
- von Willebrand disease
- DIC (usually 2ndary to sepsis)
27
What will a platelet count of less than 50 cause?
- spontaneous bruising + prolonged bleeding times
| - nosebleeds, bleeding gums, heavy periods, easy bruising, blood in urine/stool
28
What are those with a platelet count of less than 10 at risk of?
SPONTANEOUS BLEEDING
- intracranial bleeds or GI bleeds
- require platelet transfusion
29
How do you manage ITP?
CONSERVATIVE
1. Prednisolone
2. IVIG
3. Rituximab
4. Splenectomy
- monitor platelet count + educate pt re concerning signs of bleeding
30
How do you diagnose heparin induced thrombocytopenia?
Test for HIT antibodies in blood
31
What investigations diagnose von Willebrand Disease?
1. Prolonged bleeding time
2. APTT may be prolonged
3. Factor VIII levels may be moderately reduced
4. Normal platelets
32
How is von Willebrand disease managed?
Does not require day-to-day treatment
In response to major bleeding/trauma/pre-op:
1. Desmopressin - stimulate release of vWF
2. Infuse vWF
3. Factor VIII infusion
33
How is thrombophilia diagnosed?
PROLONGED APTT
| - bleeding time, thrombin time, prothrombin time are all normal
34
How do you manage thrombophilia?
1. Replace factor 8 or 9 by IVI
2. For ACUTE episodes:
- infusions of clotting factors or FFP
- desmopressin to stimulate release of vWF
- tranexamic acid
35
What are some causes of DIC?
- sepsis
- trauma
- obstetric complications e.g. amniotic fluid embolism or HELLP syndrome
- malignancy
36
How do you investigate + diagnose DIC?
1. Low platelets
2. Prolonged APTT, PT and bleeding time
3. Fibrin degradation products are often raised
schistocytes due to microangiopathic haemolytic anaemia
37
How do you manage DIC?
Find + address underlying cause
1. RESUS
- A+B: consider airway support + O2
- C: IV access, consider fluids, blood, platelets + FFP
- discuss with ICU
38
What are some risk factors for PAD?
- older age
- FHx
- male
- smoking + alcohol
- poor diet
- minimal exercise
- obesity
- diabetes
39
What is Leriche's syndrome?
```
Occlusion in distal aorta or common iliac artery.
Triad of:
1. Thigh/buttock claudication
2. Absent femoral pulses
3. Male impotence
```
40
What are the 6 P's of critical limb ischaemia?
1. Pallor
2. Pulseless
3. Perishingly cold
4. Paraesthesias
5. Pain
6. Paralysis
41
What investigations should be performed in PAD?
1. ABPI
- over 0.9 = normal
- 0.6 to 0.9 = mild
- 0.3 to 0.6 = moderate-severe
- Less than 0.3 = severe, leading to critical limb ischaemia
2. Arterial doppler USS
3. Angiography (CT/MRI)
4. R/O: DM, arthritis (CRP/ESR), anaemia, renal disease, dyslipidaemia, cardiac ischaemia (ECG), thrombophilia
42
What management for PAD can be done to help manage risk factors?
1 QUIT smoking
2. Treat HTN + high cholesterol
3. Supervised exercise programmes
43
What medical/surgical interventions can be used in PAD?
```
MEDICATIONS:
- Atorvastatin 80mg
- Clopidogrel 47mg
- Naftidrofuryl oxalate (peripheral vasodilator)
SURGICAL:
- percutaneous transluminal angioplasty
- surgical reconstruction
- amputation
```
44
What is the difference between wet + dry gangrene?
```
WET = tissue death AND infection
DRY = death but no infection
```
45
How is wet gangrene managed?
Analgesia
broad spec Abx
Surgical debridement
Amputation
46
How is dry gangrene managed?
Manage with restoration of blood supply + amputation
47
What are the clinical features of necrotizing fasciitis?
ACUTE
- painful, erythematous lesions develop
- often worsening cellulitis with pain out of keeping with physical features
- extremely tender over infected tissue
48
How do you manage necrotizing fasciitis?
1. Urgent surgical debridement
| 2. IV Abx
49
How do you manage cellulitis?
```
MILD-MODERATE:
- flucloxacillin
- clarithromycin if pregnant
- doxycycline if penicillin allergic
SEVERE:
- co-amoxiclav, cefuroxime, clindamycin or ceftriaxone
```
50
What investigations are performed in suspected chronic venous insufficiency?
1. Duplex USS - venous reflux
2. Ascending phlebography
3. CT/MR venography
4. CT abdo/pelvis - r/o masses compressing iliac vein
51
How is chronic venous insufficiency managed?
1. Grading compression stocking
- emollient can be added to combat eczematous changes
2. Endovenous ablation or saphenectomy = surgical stripping
3. Injection sclerotherapy
52
What examinations/tests should be done to diagnose varicose veins?
1. INSPECTION - start with pt standing
- ulcers, venous eczema, haemosiderin
- palpate veins for tenderness (phlebitis) or hardness (thrombosis)
- if ulcers present, palpate pulses to R/O PAD
2. COUGH IMPULSE at sapheno-femoral junction - indicates incompetence of valve
3. AUSCULTATE over varicosities for bruits (indicate AV malformation)
4. Examine abdomen, pelvis in F + external genitalia in M
5. Doppler USS
53
How are varicose veins managed?
1. Treat any underlying cause
2. Education:
- avoid prolonged standing, elevate legs where possible
- support stockings
- lose weight, regular walks
3. Endovascular treatment
- radiofrequency ablation
- endovenous laser ablation
- injection sclerotherapy
4. Surgery
- saphenofemoral ligation
- stripping from groin to upper calf
54
Name some risk factors for VTE. As many as possible.
GENERAL
- increasing age, obesity, FHx, pregnancy, immobility, hospitalisation, anaesthesia
UNDERLYING CONDITIONS
- malignancy, thrombophilia, Factor V Leiden, HF, antiphospholipid, Bechet's, polycythaemia, nephrotic syndrome, sickle cell, PNH, hyperviscocity syndrome, homocystinuria
MEDICATIONS
- COCP, HRT, tamoxifen, raloxifene, antipsychotics especially olanzapine
55
What amount of calf swelling is significant for a DVT? How is it measured?
More than 3cm difference between legs
| - circumference of calf 10cm below tibial tuberosity
56
What number of Well's score indicates DVT is likely?
2 or more
57
If you have intermediate suspicion of VTE, how do you manage in terms of anticoagulation?
Commence if the results of the diagnostic tests are expected to be delayed 4 hours or more
58
What further tests/management should be done in patients with an unprovoked DVT/PE who are NOT known to have cancer?
- Physical exam
- CXR
- bloods = FBC, Ca, LFTs
- urinalysis
- thrombophilia screening = antiphospholipid antibodies (anti-cardiolipin) + hereditary thrombophilia testing if unprovoked DVT/PE in 1st degree relative.
59
What advice should you give to patients post PE/DVT?
- Engage in regular exercise/walking once discharged
- Elevate affected leg when sitting
- Extended travel OR travel by plane should be delayed for at least 2 weeks after starting anticoagulants
60
What % of carotid artery stenosis is indicative for carotid artery endarterectomy?
More than 70%
61
When do you get schistocytes on blood film?
Fragments of RBCs - indicates trauma to RBCs
| - can be present in HUS, DIC, TTP, metallic heart valves + haemolytic anaemia
62
When do you get smudge cells on blood film?
Ruptured WBCs which can indicate CLL
63
When do you get sideroblasts on blood film?
Immature RBCs which occur when bone marrow is unable to incorporate iron into Hb molecules - can indicate myelodysplastic syndrome
64
What will iron studies show in IDA?
Low or normal ferritin
High TIBC
High transferrin saturation
65
What are the side effects of EPO injections?
Flu-like symptoms, hypertension, rise in platelets + risk of VTE
66
What medications can cause folate deficiency?
anti-epileptics e.g. phenytoin, valproate
methotrexate
trimethoprim
67
What is pernicious anaemia?
Autoimmune condition where antibodies form against parietal cells or intrinsic factors
- preventing absorption of vitamin B12
68
How do you manage hereditary spherocytosis?
Presents with jaundice, gallstones, splenomegaly + aplastic crisis in presence of parovirus
- raised MCHC
- raised reticulocytes
- spherocytes on blood film
69
How do you treat hereditary spherocytosis?
1. Folate supplementation + splenectomy
| 2. Cholecystectomy may be required
70
How do you manage sickle cell disease?
1. Avoid dehydration + other triggers of crises
2. Ensure vaccines up to date
3. Abx prophylaxis = penV
4. Hydroxycarbamide - stimulate foetal Hb (does not lead to sickling of RBCs)
5. Blood transfusions if severe anaemia
6. Bone marrow transplant can be curative
71
How do you manage iron overload in thalassaemias?
Limiting transfusions + iron chelation (desferroximine)
72
If pts are not bleeding, at what platelet count do they require a tranfusion?
Below 10 - at risk of spontaneous bleeds
73
How do you manage immune thrombocytic purpura?
- prednisolone
- IVIG
- rituximab
- splenectomy
74
How is heparin induced thrombocytopenia diagnosed + managed?
Test for HIT anotbodies in blood
| Manage by stopping heparin + using alternative anticoagulant
75
How do you diagnose von Willebrand disease?
Based on hx, FHx and
- prolonged bleeding time (PT)
- APTT may be prolonged
- factor VIII may be slightly reduced
76
How do you manage vWD?
does NOT require any day-to-day treatment
Management in response to major bleeding/trauma/in preparation for ops:
1. Desmopressin to stimulate release of vWF
2. vWF infusion
3. Factor VIII infusion along with plasma derived vWF
77
What will the coagulation profile show in haemophilia?
Prolonged APTT
| - bleeding time, thrombin time + prothrombin time all normal
78
What are some causes of DIC?
- sepsis
- trauma
- obstetric complications e.g. aminiotic fluid embolism or hemolysis, elevated liver function tests, and low platelets (HELLP syndrome)
- malignancy
79
What investigations are done in DIC + what do they show?
- low platelets
- prolonged APTT, prothrombin and bleeding time
- fibrin degradation products are often raised
- schistocytes due to microangiopathic haemolytic anaemia
80
What investigations should you perform in suspected leukaemia?
1. FBC - take within 48h if suspected leukaemia
2. Blood film
3. LDH - often raised
4. Bone marrow biopsy = gold standard
5. CXR
6. Lymph node niopsy
7. LP (?CNS involvement)
8. CT/MRI/PET
81
WHat are your DDx for petechiae?
- NAI
- leukaemia
- meningococcal septicaemia
- vasculitis
- HSP
- ITP
82
WHat is seen on blood film in ALL + AML?
Blast cells
83
WHy in ALL is there is a risk of infection, anaemia + bruising?
Cancerous cells fill the bone marrow so healthy RBCs + platelets cannot be made
84
What conditions is AML associated with? Who is at greater risk of developing?
Associated with MDS + aplastic anaemia
| - children with Down's + Li-Fraumeni syndrome
85
What investigations are performed in suspected Hodgkin's Lymphoma? What do they show?
1. Bloods - FBC, film, ESR, LFT, LDH, urate, Ca
2. LDH - raised
3. Lymph node biopsy
- Reed-Sternberg cells
4. CT/MRI/PET
86
Name 3 examples of non-Hodgkins lymphomas?
1. Burkitt = associated with RBV, malaria + HIV
2. MALT = mucosa-associated lymphoid tissue = usually around stomach + associated with H. pylori
3. Diffuse large B cell = rapidly growing painless mass in over 65s
87
What are the tests you perform in suspected myeloma?
1. FBC - low WCC
2. Ca - raised
3. ESR - raised
4. Plasma viscosity - raised
Then serum + urine electrophoresis
- bone marrow biopsy to confirm diagnosis
88
What imaging would you perform in myeloma to assess for bone lesions?
1. Whole body MRI
2. Whole body CT
3. Skeletal survey by x-ray
89
What mutation is present in polycythaemia rubra vera?
JAK2
90
What are the symptoms + signs of polycythaemia rubra vera?
often asymptomatic
- hyperviscosity = headaches, dizzy, tinnitus, visual disturbance
- itchy after hot bath + burning in finger and toes
- facial plethora
- splenomegaly
- gout
- features of arterial or venous thrombosis
91
What investigations are performed in polycythaemia rubra vera?
1. FBC - raised RCC, Hb, HCT, PCV (raised WCC + platelets)
2. B12 - raised
3. Marrow - hypercellularity with erythroid hyperplasia
4. Reduced serum EPO
5. Raised red cell mass on Cr studies + splenomegaly in setting of normal PaO2 is diagnostic
92
How do you treat polycythaemia rubra vera?
Aim to keep HCT below 0.45
1. Hydroxycarbamide if high risk
2. Venesection if low risk
3. Aspirin 74mg OD
93
In what condition do you get teardrop RBCs?
myelofibrosis
94
What are some inherited causes of thrombophilia?
Factor V Leiden
Prothrombin gene mutation
Protein C+S deficiency
Antithrombin deficiency
95
What are some acquired causes of thrombophilia?
COCP
| Anti-phospholipid syndrome
