Triple A, Shock & Peripheral Vascular Exam

1. Triple A, Shock & Peripheral Vascular Exam By Amy Kitchen

2. Aims: Triple AAA Shock Peripheral Vascular Exam (OSCE style) MCQs

3. Abdominal Aortic Aneurysm

4. What is a triple A? An aneurysm is a permanent and irreversible dilatation of a blood vessel by at least 50%. A normal abdominal aorta is 2cm and once over 3cm it is an aneurysm. Most arise from below the renal arteries and position is important for surgery. They are caused by degradation of the elastic lamellae, a leukocytic infiltrate, enhanced proteolysis and smooth muscle cell loss. Quicker growth means increased risk of rupture

5. Risk Factors/Causes Atherosclerosis, other arterial pathology Family History Smoking Being male Aging Hypertension COPD Hyperlipidaemia Interestingly - less chance if diabetic.

6. Presentation • Uncomplicated – asymptomatic – incidental finding. Perhaps some abdominal or groin pain. • Ruptured: Severe, sudden abdominal/groin pain. Syncope. Shock. Collapse. If in peritoneal cavity, unlikely to survive ambulance trip. If retroperitoneal, may be contained initially with temporary seal. • Exam signs: Pale, pulsatile, expansile mass, shock, Grey-Turners sign

7. Investigations Bloods: FBC, U&E, LFT, Clotting, Cross-match, ESR, CRP. ECG Imaging: CXR. USS, CT, MRI angiogram.

8. Management • Uncomplicated • <5.5cm monitor. • 3.0-4.4 annual. • 4.5-5.4 3-monthly. • >5.5 surgery. • Reduce risk factors: smoking, BP, statin, antiplatelet (if appropriate). Other medications (doxycycline, ACE-I/ARB, statin, aspirin). • Surgery: EVAR or open. EVAR needs aneurysm to be at least 1.2cm below renal arteries. • Emergency: A to E assessment

9. Screening & Prognosis • Screening: • An ultrasound scan for men between the ages of 65-74. • Men are invited after their 65th birthday. • Screen high-risk patients (including women) if they have a family history or other risk factors. • Prognosis • Rupture = 80% mortality. • Most die before reaching hospital. • 50% mortality in those who make it to surgery. • If no surgery and >5.5cm – 20% mortality per year.

10. Shock

11. Definition & Types • Shock = Hypoperfusion which results in cell damage and death • Types of shock: • Obstructive/Cardiogenic • Hypovolaemic • Distributive (septic, anaphylactic and neurogenic)

12. Obstructive & Cardiogenic Mechanism: Prevents effective pumping of the heart either by direct (cardiogenic) or indirect (obstructive) insult. Cardiogenic: MI. Obstructive: Pulmonary embolus, Pneumothorax. Signs & symptoms: lethargy, cool/clammy/pale/cyanotic extremities. Weak pulses, tachypnoea, hyperventilation, hypotension. Management: A to E assessment. Take care with fluids as it can lead to overload. Treat underlying cause.

13. Hypovolaemic Mechanism. A sudden loss of volume in circulating blood. Causes could include trauma, ruptured AAA, burns, D&V, pancreatitis. Signs & symptoms: lethargy, cool/clammy/pale/cyanotic extremities. Weak pulses, tachypnoea, hyperventilation, hypotension Management: A to E assessment, group and save bloods, fluid resuscitation and transfusion. Monitor observations and bloods.

14. Anaphylactic Mechanism: Histamine release leads to huge, widespread, vasodilation. Signs & symptoms: flushing, pruitus, urticaria, hypotension, tachycardia, angioedema, wheezing, stridor, cyanosis, syncope. Management: A to E assessment. Oxygen, Fluids, Adrenaline IM, antihistamine, intubation. Corticosteroids may help late-phase reaction.

15. Septic Mechanism: release of toxins from pathogens that lead to vasodilation. Signs & symptoms: pyrexia, chills, hypotension, symptoms relevant to source of infection (productive cough, dysuria etc.), confusion, tachycardia, tachypnoea Management: SEPSIS 6 (Give 3/take 3): Oxygen, antibiotics, fluids, blood cultures, lactate, urine output.

16. Neurogenic Mechanism: Trauma to nervous system resulting in loss of sympathetic chain signal, leading to vasodilation. Signs & symptoms: hypotension, confusion, syncope, sometimes bradycardia, hypothermia Management: very difficult to treat. A-E approach. Fluids, inotropic agents (dopamine), atropine, steroids. Surgery.

17. Peripheral Vascular Exam

18. Introduction Read Question Carefully, what exactly do they want? Venous, lower limb, everything? Wash hands Introduce yourself Check patient details Gain consent Adequately expose Check if there is any pain

19. General inspection Patient well/ comfortable at rest? Mobility aids General appearance of arms and legs Compression stockings Cigarettes Oxygen

20. Upper Limbs • Inspection: Cyanosis/pallor, tar-staining, tendon xanthomas, gangrene • Palpation: Temperature, capillary refill time. • Pulses: • Radial – rate, rhythm, radio-radial delay • Brachial – assess volume • Blood pressure: in both arms (acknowledge – don’t actually need to do this, just mention it) • Carotid – Palpate (NEVER simultaneously), Auscultate for bruit and avoid palpating due to emboli risk.

21. Abdomen Inspect – any obvious pulsation Palpate – feeling either side for expansion Auscultate – Bruits

22. Lower Limbs: Inspection Look for scars, hair loss, discolouration, pallor, missing limbs/toes, ulcers, muscle wasting and ask patient to wiggle their toes. Look between every toe and beneath feet Venous ulcer (painless, sloping edges), arterial ulcer (painful, punched out), neuropathic (reduced sensation, pressure points) Venous signs: varicose veins (view standing), oedema, venous eczema, haemosiderinosis, lipodermatosclerosis, atrophie blanche Arterial signs: Trophic changes (nails/skin), hair loss, scar from saphenous harvest, ulcers.

23. Lower Limb: Palpation & Pulses Both: Temperature & capillary refill Just venous: Feel calf for tenderness and offer to measure circumference 10cm below tibial tuberosity (if DVT suspected). Palpate for oedema. Dorsalis pedis, posterior tibial, popliteal and offer femoral. If dorsalis pedis and posterior tibial are present, the rest are likely to be fine. Always be honest about whether you can feel them (some patients have signs). Auscultate for bruits. Use doppler if pulses cannot be felt.

24. Lower Limb: Sensation & Buerger’s Test • Perform a gross assessment of peripheral sensation, starting distally. • Buerger’s Test • Raise patient’s feet to 45o for 2-3 minutes. • Observe for pallor and if this occurs, what angle. (20o = Buerger’s angle) • Once the time limit has been reached – ask patient to place legs over side of bed – observe for reactive hyperaemia.

25. To Complete Wash hands, thank patient and summarise findings. Perform an Ankle-Brachial Pressure Index (ABPI) . Leg/Arm ratio. Take a full history Look at basic observations Cardiovascular examination Full neurological examination – especially lower limb.

26. The 6 Ps of Critical Limb Ischaemia Pulseless Painful Pallor Perishingly Cold Paraesthesia Paralysis

27. MCQs

28. A 52-year-old man visits you at the GP. He tells you his father recently passed away after a ruptured abdominal aorta. What is the screening programme in the UK for abdominal aortic aneurysm? • A single USS at the age of 65 years. • Annual USS between the ages of 50-65 • 3-yearly USS between the ages of 50-65 • No screening programme • 5-yearly USS between 50-65

29. A 52-year-old man visits you at the GP. He tells you his father recently passed away after a ruptured abdominal aorta. What is the screening programme in the UK for abdominal aortic aneurysm? Additional information – If a patient is high risk, then they can still be referred for an ultrasound scan. • A single USS at the age of 65 years. • Annual USS between the ages of 50-65 • 3-yearly USS between the ages of 50-65 • No screening programme • 5-yearly USS between 50-65

30. A patient is diagnosed with an abdominal aortic aneurysm. On the ultrasound scan, it measured 4cm. What is the most appropriate management plan? • No further action • 3-monthly ultrasound scans • Annual ultrasound scans • Endovascular Aneurysm Repair • Open surgical repair.

31. A patient is diagnosed with an abdominal aortic aneurysm. On the ultrasound scan, it measured 4cm. What is the most appropriate management plan? • No further action • 3-monthly ultrasound scans • Annual ultrasound scans • Endovascular Aneurysm Repair • Open surgical repair.

32. Which of the following options is not a sign of venous pathology in the lower limb. Varicose eczema Punched-out, painful ulcers Lipodermatosclerosis Atrophie Blanche Oedema.

33. Which of the following options is not a sign of venous pathology in the lower limb. Additional information – this is the description of arterial ulcers. Venous ulcers are painless with sloping edges. Varicose eczema Punched-out, painful ulcers Lipodermatosclerosis Atrophie Blanche Oedema.

34. Which type of shock is most associated with histamine release? Cardiogenic Hypovolaemic Neurogenic Anaphylactic Septic

35. Which type of shock is most associated with histamine release? Cardiogenic Hypovolaemic Neurogenic Anaphylactic Septic

36. A 70 year old man collapses suddenly. He is pale, his blood pressure is 90/50, temperature 37.0 degrees and he looks very unwell. ECG showed a sinus tachycardia. His wife said he had been complaining of back pain before he lost consciousness. What type of shock is this likely to be? Cardiogenic Hypovolaemic Neurogenic Anaphylactic Septic

37. A 70 year old man collapses suddenly. He is pale, his blood pressure is 90/50, temperature 37.0 degrees and he looks very unwell. ECG showed a sinus tachycardia. His wife said he had been complaining of back pain before he lost consciousness. What type of shock is this likely to be? Cardiogenic Hypovolaemic Neurogenic Anaphylactic Septic Additional information – on this occasion, it is likely that the shock was caused by an acute blood loss – a triple A.

38. Useful sites NICE Patient.co.uk Merck Manuals Oxford Handbook + Oxford Assess & Progress. Geeky Medics Oscestop