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Royal College: Emergency Medicine > Vascular System > Flashcards

Vascular System Flashcards

This deck covers Chapters 75-78 in Rosens, compromising all of vascular medicine.

1
Q

List 8 risk factors for aortic dissection

A
  1. Age
  2. Male
  3. HTN
  4. Cardiac surgery
  5. Bicuspid valve
  6. FHx
  7. Ehlers-Danlos
  8. Marfan’s
  9. Cocaine use
  10. Trauma
  11. Exertion
  12. IABP insertion
  13. Congenital heart disease
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2
Q

List 2 classification systems for aortic dissection

A

Stanford (2 syllables)

  • Type A - ascending
  • Type B - descending

DeBakey (3 syllables)

  • Type I - ascending + descending
  • Type II - ascending
  • Type III - descending
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3
Q

List 10 findings on CXR for aortic dissection.

A
  1. Wide mediastinum
  2. Abnormal aortic contour
  3. Calcium sign
  4. Double egg sign
  5. Loss of PA window
  6. Loss of aortic knob
  7. Apical cap
  8. Pleural effusion
  9. Displacement of NG right
  10. Right mainstem displaced right
  11. Left mainstem displaced down
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4
Q

What is your HR and BP target in aortic dissection? Which do you get first?

A
  • HR < 60 bpm
  • sBP <110 mmHg

Achieve HR goal first to avoid reflex tachycardia

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5
Q

List 2 reasons why NIFEDIPINE should not be used in aortic dissection.

A
  1. Reflex tachycardia
  2. Doesn’t slow HR
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6
Q

List 4 risk factors for AAA. What is the most important risk factor for the risk of rupture?

A
  1. Age
  2. Male
  3. FHx
  4. HTN
  5. Smoking
  6. DLD

Rate of size increase is most concerning

Size >5.5 cm = surgery

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7
Q

List 7 complications that can arise from an INTACT AAA

A
  1. Rupture
  2. Aortic thrombosis
  3. Embolization
  4. Paralysis
  5. AKI
  6. Limb ischemia
  7. Aortocaval fistula
  8. Aortoenteric fistula
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8
Q

List 4 late complications of AAA repair

A
  1. Endoleak
  2. Infection
  3. Aortoenteric fistula
  4. Pseudoaneurysm
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9
Q

Explain the 4 types of endoleak

A

Type I

  • Leak from end of graft

Type II

  • Leakage into aneurysm sac from branch vessels

Type III

  • Leak between stent components

Type IV

  • Leak through graft material
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10
Q

How is arterial embolism best managed?

A

Embolism

  • Fogarty Catheter Embolectomy

Thrombus

  • Fogarty Catheter Embolectomy
  • Bypass Graft

Non-Limb Threatening

  • Heparin
  • Intra-arterial tPA

Amputate if irreversible ischemia

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11
Q

What is Buerger’s sign?

A
  • Patient supine, raise leg 45 degrees
  • When feet have pallor, sit with hanging over edge
  • Normal if colour returns in 10-15s
  • Advanced ischemia if >20s
  • Ischemic if cyanotic first, then red
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12
Q

How do you differentiate embolus from thrombosis?

A

Embolus

  • Usually have afib
  • Other leg is normal, no claudication
  • Sharp demarcation of ischemia
  • Few collaterals

Thrombus is opposite

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13
Q

What are the 5 diagnostic criteria of Buerger’s disease? What is the only treatment?

A
  1. Smoker
  2. Absence of atherosclerotic risk factors
  3. Onset <50 yo
  4. Infrapopliteal arterial occlusions
  5. Upper limb involvement

Treatment

  • Stop smoking
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14
Q

Differentiate phlegmasia cerulea dolens & phlegmasia alba dolens

A

Phlegmasia cerulea dolens

  • Massive iliofemoral DVT
  • Cyanotic leg

Phlegmasia alba dolens

  • Arterial insufficiency from massive iliofemoral DVT
  • White leg
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15
Q

List 5 diagnostic criteria for Raynaud’s disease.

A
  1. Symptoms >2yr
  2. Worse in cold/emotion
  3. Bilateral
  4. No gangrene
  5. No disease that causes Raynaud’s phenomenon
  6. Scleroderma, SLE, RA

White –> Blue –> Red

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16
Q

22 yo male with months of severe pain in the ulnar distribution of his left arm. Worse at work (stocks overhead shelves). Diagnosis? Best test?

A

Thoracic Outlet Syndrome

Elevated Arm Stress Test (EAST)

  • Most reliable screening test
  • Abduct arm and elbow to 90 degrees
  • Open/close fists for 3 min
  • Positive if:
  • Early fatigue
  • Numb hand
  • Progressive aching to top of arm/shoulder
17
Q

List 8 DDx for DVT

A
  1. Muscle strain, hematoma
  2. Baker’s cyst
  3. Lymphedema
  4. Cellulitis
  5. Vasculitis
  6. Fracture
  7. Superficial phlebitis
  8. Chronic venous insufficiency
  9. Proximal venous compression (pregnancy, tumour)
  10. CHF
  11. Hypoalbuminemia
18
Q

What are the 10 components of the Well’s Score for DVT?

A

C3P3O R2D2 - note it is not C3PO

  1. Cancer
  2. Collateral superficial veins
  3. Calf swelling >3 cm larger than other
  4. Pitting edema
  5. Previous DVT
  6. Pain along the deep venous system
  7. Oedema of the entire leg
  8. Recent immobilization
  9. Recent surgery (3mo)
  10. Different diagnosis more likely (-2)

If 2+, get U/S. If 0/1, get D-dimer

19
Q

List the dose of the following mediations in treatment of DVT:

  • UFH
  • Enoxaparin
  • Dalteparin
  • Rivaroxaban
A
  • UFH 80 units/kg IV bolus, then 18 units/kg IV infusion
  • Enoxaparin 1 mg/kg SC BID
  • Dalteparin 100 units/kg SC BID
  • Rivaroxaban 15 mg PO BID
20
Q

Name 3 absolute contraindications for treating a proximal DVT.

A
  1. Active bleeding
  2. Bleeding diathesis
  3. PLT <20
  4. Intracranial bleed
  5. Recent NSx/Ocular Sx
21
Q

What are the 7 components of the Well’s Score for PE?

A

Don’t Die Tell Team To Calculate Criteria

  1. DVT symptoms (3)
  2. Diagnosis most likely PE (3)
  3. Tachycardia (1.5)
  4. Three days immobilized/30 days surgery (1.5)
  5. Thromboembolism in the past (1.5)
  6. Cancer (1)
  7. Coughing blood (1)

If score >4, CT. If score 4 or less, D-dimer

22
Q

What are the 8 criteria in the PERC rule?

A

HAD CLOTS

  1. Hormones
  2. Age >50
  3. DVT/PE history
  4. Coughing blood
  5. Leg swelling
  6. Oxygen >95%
  7. Tachycardia
  8. Surgery in last month
23
Q

What are 5 CXR findings of PE?

A
  1. Hampton’s hump
    * Wedge-like opacity at the edge (infarct)
  2. Westermark’s sign
    * Unilateral lung oligemia
  3. Fleischner’s sign
    * Enlarged pulmonary artery
  4. Pleural effusion
  5. Unilateral basal atelectasis
24
Q

List 5 ECG findings that can occur with PE

A
  1. Sinus tachycardia
  2. TWI V1-V4
  3. RBBB
  4. RAD
  5. S1Q3T3
  6. ST changes
  7. Afib
25
Q

What are 6 treatments available in massive PE?

A
  1. Anticoagulation
  2. Fluid resuscitation
  3. Vasopressors/Inotropes
  4. tPA
  5. Catheter-directed tPA
  6. Embolectomy
26
Q

What is the dose of tPA in massive PE? How do you give it?

A

Dose = 0.9 mg/kg

The administration is contentious.

  • If dead, 50% upfront, 50% over 1 hr
  • If not dead, perhaps 15% upfront, 85% over 1 hr
27
Q

Define massive PE

A
  • Cardiac arrest
  • Profound hypotension (sBP <90)
  • Bradycardia <40 bpm
28
Q

List 3 indications for tPA in massive PE

A
  1. Cardiac arrest
  2. Persistent hypotension
  3. Cardiogenic shock

These are basically the definition of massive PE

29
Q

List 8 absolute contraindications for tPA

A

Absolute

  1. Active bleeding
  2. AVM
  3. Brain cancer
  4. ICH
  5. Aortic dissection
  6. Severe hypertension
  7. Closed head injury within 3 months
  8. Stroke within 3 months
  9. Brain/Spine Sx within 2 months
30
Q

List 8 relative contraindications for tPA

A

Relative

  1. Severe hypertension
  2. Other intracranial diseases
  3. CPR >10 min
  4. Surgery within 3 weeks
  5. GI bleed within 3 weeks
  6. Plt <100
  7. Non-compressible vascular access
  8. Pregnancy
  9. OAC

Royal College: Emergency Medicine (25 decks)

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