What is the consequence of limb reperfusion after 4-6 hours of arterio-occlusive ischemia.
Intracellular and interstitial edema
At what pressure within the muscular fascial compartment does edema result in compartment syndrome?
Pressures > 30mmHg
What are two important early complications of operation on the abdominal aorta (i.e. AAA repair)?
- Bowel ischemia
2. Bowel infarction
What must be ruled out in ANY patient who suffers a blunt deceleration trauma?
blunt aortic trauma/injury
Note, deceleration traumas include MVA and free fall from > 10 feet.
What is the initial screening/work done for a patient with deceleration trauma?
CXR
Diagnosis:
Blunt aortic trauma on CXR
- Widening of the mediastinum (most sensitive)
2. Deviation of the trachea (possible)
Work-up:
Peripheral arterial disease in a symptomatic patient
Ankle-brachial index
ABI is noninvasive and both highly sensitive and highly specific. It is the preferred first step to confirm the diagnosis of PAD in most cases.
Clinical Manifestation:
Patient s/p cardiac surgery with:
- fever
- chest pain
- leukocytosis
- mediastinal widening on CXR
Acute mediastinitis
Treatment:
Acute Mediastinitus
- Drainage
- Surgical debridement
- Prolonged antibiotic therapy
Diagnosis:
CXR with:
- Widened mediastinum
- Left-sided hemothorax
Most likely aortic injury due to high-energy, blunt, rapid deceleration trauma.
Clinical Manifestation:
Acute, sharp tearing chest or back pain
Aortic dissection needs to be at the TOP of the list.
What would happen if an aortic dissection extended to the following vessels:
- carotid arteries
- renal arteries
- spinal arteries
- Stroke
- Acute renal failure
- Lower-extremity weakness or paraplegia
What is another name for acute arterial occlusion?
Limb ischemia
Clinical manifestation:
Acute arterial occlusion (Limb ischemia)
Remember the 5 P’s!
- Pain
- Pallor
- Pulselessness
- Parasthesias
- Paralysis
Treatment:
Acute arterial occlusion (Limb ischemia)
- Immediate anticoagulation
2. Emergency vascular surgery referral
What is another name for aortoiliac occlusion?
Leriche syndrome
Clinical Manifestation:
Leriche syndrome
- Bilateral hip, thigh and buttock claudication
- Impotence
- Symmetric atrophy of the bilateral lower extremities
Diagnosis:
Patient with:
- acute onset back pain
- profound hypotension
This is ruptured abdominal aortic aneurysm until proven otherwise! This patient needs to go to the operating room immediately.
Clinical manifestation:
Embolic arterial occlusion
- sudden onset severe pain
- asymmetric pulselessness
Also, the 5 P’s! (pain, pallor, pulselessness, parasthesia & paralysis).
What complication of cardiac catheterization often presents with:
- sudden hemodynamic instability
- flank or back pain
Retroperitoneal hematoma
Flank or back pain is typically ipsilateral.
Diagnosis:
Retroperitoneal hematoma
1a. non-contrast CT of the abdomen and pelvis -OR-
1b. abdominal ultrasound
Treatment:
Retroperitoneal hematoma
- bed rest
- intravenous fluids
- blood transfusion (if IV fluids fail)
Diagnosis:
- increased jugular venous distention
- tachycardia
- hypotension despite aggressive fluid resuscitation
in a patient with a history of blunt chest trauma
acute cardiac tamponade
Diagnosis:
CXR in acute cardiac tamponade
- Normal cardiac silhouette
2. LACK of tension pneumothorax
