Thoracic Aortic Aneurysm:

structures involved

what causes the aneurysms in these structures

structures involved:

what causes the aneurysms in these structures

Ascending aorta-Degeneration 25%

Transverse arch, Descending, Thoracoabdominal

Atherosclerosis

Traumatic

Crawford Classification:

Extent I -involve most of the descending thoracic aorta from the left subclavian artery down to vessels in the abdomen.  renal arteries are not involved 

 Extent II -begin at the left subclavian artery and reach the infrarenal abdominal aorta even as far as the inguinal area

 Extent III- involve the distal half or less of the descending thoracic aorta and substantial segments of the abdominal aorta

 Extent IV-involve the upper abdominal aorta and all or none of the infrarenal aorta

Thoracic Aortic Aneurysm:

S&S

Dx

S&S

Asymptomatic

Chest pain, Stridor, Hemoptysis, Hoarseness

Dx:

Incidential find on CXR

CT, MRI, Aortography

AAA??

Define

Etiology

Most common site

AAA: Abdominal Aorta Aneurysm

Define: Abnormal dilation of the abdominal aorta

>1.5-2 x the normal, forms true aneurysm

Etiology:  95% atherosclerosis, 5% inflammatory

Most common site: Infrarenal 95%

Triad of rupture AAA

Symptoms of AAA

Triad of rupture AAA

Abdominal mass

Pulsatile abdominal mass

Hypotension

Symptoms of AAA

Asymptomatic

Vague epigastric discomfort to back

Abdominal pain

Acute Arterial Occlusion:

common cause

epidemiology

dx

common cause: Embolization (cardiac, venous, athersclerosis,arterial thrombosis)

epidemiology:  occurs in Smokers & Hypercholestremia

dx:  Angiography, EKG, CXR, Doppler, PO2

Acute Arterial Occlusion

Presentation??

THINK 6 Ps:

Pain

Pallor

Pulselessness

Parasthesias

Paralysis

Poikitothermia (loss of nl thermoregulation)

Acute Arterial Occlusion:

Tx:  Non-operative & Operative 

Non-operative:

 Heparin IV bolus 80 units/kg of 18 units/kg/hr

PTT-maintain at b/w 60-80 secons

Thrombolysis

 Operative:

Embolectomy 

Venous Thromboembolism-DVT

Define

S&S

Define: Clot formation in pelvis or LE veins

S&S:  50% asymptomatic

LE pain

Swelling

Tenderness

Pulmonary embolism

Homan's sign

Virchow's triad

Stasis

Abnormal endothelium

Hypercoaguability

DVT:

Dx

Tx

Dx:

Duplex US

Doppler US

CT abdomen & pelvis

Tx:

Non-operative-

Low dose Heparin 80 units IV bolus of 18 units/kg/hr

Compression of extremity

Operative-

Mechanics IVC filter

Embolectomy

Catheter

Pulmonary Embolism

Define

Risk factors

S&S

Define:  DVT that embolizes to pulmonary arteries

Risk factors:  Virchow's Triad

S&S:

Pleuritc chest pain

Dyspnea

Cough

Hemoptysis

Tachycardia & Tachypnea

R sided heart strain-echo

Pulmonary Embolism:

Dx studies

Tx

Dx studies: 

 CT angiogram, CXR-westmark sign

Protein C & S, Antithrombin 3, Factor V leiden

Tx:

Anticoagulation

If anticoagulation contraindicated Mechanical filter

Surgery:  Trendlenberg opertion

 for PROFOUND HYPOTENTION & HYPOXIA

"Pulmonary Artery Embolectomy"

Renal Dialysis Shunt:

When is it indicated??

1. Fluid overload

2. Refractory Hyperkalemia

3. BUN > 130 or 100

4. Serum Creatinine > 10 mg/dL

5. Acidosis

6. Uremic complications: Encephalopathy, Pericardial effusion

Compartment Syndrome:

Define

Causes

Define:  Increased pressure within an osteofascial compartment that leads to ischemic necrosis

Causes:

Fx

Vascular compromise

Reperfusion injury

Compressive dressings

Can occur after any musculoskeletal injury

Compartment syndrome:

Dx

S&S

Dx: Measure comparment pressure, most muscle compartments are lower than 10 mm Hg to 0

S&S:

Symptoms: Pain, Parasthesias, Paralysis

Signs: PROM pain-out of proportion

Cyanosis/Pallor

Hypoesthesia ( decreased sensation, 2 point discrimination)

Firm compartment

Compartment syndrome:

Tx??

Pressure lower than 10-NO treatment

15-20:  Reeval in 12 hrs

Higher 20:  Admit & surgery consult

Higher 30-40: IMMEDIATE FASCIOTOMY

with in 4 hrs & maximum b/w 6-8 hrs

??

Narrowing of 1 or more coronary arteries from atherosclerosis dz.  This limits blood flow to the myocardium.

What is:

Angina Pectoris

Unstable angina

Angina Pectoris:  Pressure assoc w/ exertion in chest, jaw, left arm

Unstable angina:  Angina at rest, new onset of angina, cresendo angina, post infarct angina

Fatigue

Dyspnea on exertion

SOB

Orthopnea

Face/Neck pain

Indigestion/Dyspepsia

CAD:

DX

Tx

DX: EKG, CXR, ETT, Thallium stress test

Tx: 

 Medical-dilate coronary vasculature, reduce myocardial O2 consumption, prevent further atherosclerosis, inhibit platelet activation & clot formation

Catherization, Surgery-CABG

Internal Mammary Artery/Internal Thoracic Artery

Radial Artery

Gastroploic Artery

Inferior Epigastric Artery

Stroke

Adenarthrectomy:  atherosclerotic plaque is removed

Fatigue

Dyspnea

Angina

Syncope

Arrhythmias

CHF

What murmurs are present for the following:

Aortic stenosis:  Systolic ejection

Aortic regurgitation: Diastolic decrescendo

Mitral stenosis:  Open snap, Diastolic

Mitral regurgitation: Holostic

Tricuspid: Systolic

??

HTN caused by high levels of renin & angiotensin II

this is produced by underperfused kidneys

What causes renovascular HTN

PE

Tests

Cause:  renal artery stenosis=narrowing of renal artery lumen

PE:  bruits in epigastic, subcostal, flank

unilateral small kidney

test:  Arterigraphy TOC

Catopril radionucleotide renal scan

MR angiography

symptoms:  Severe pain out of proportion to exam

Vomitting

Diarrhea/hyperdefication

Heme in stools

 triad:  Acute onset of pain

Vomitting, Diarrhea or both

Hx of A-fib, heart disease 

What is appendicitis?

Causes??

Inflammation of the appendix caused by an obstruction of the appendix lumen

Causes:  Lymphoid hyperplasia

Fecalith

Rare-parasite, foreign body, tumor

1. Periumbical pain

2. N/V

3. Anorexia

4. Pain migrates to RLQ-constant & intense, usually less than 24 hrs

1. Guarding, muscle spasm

2. Low grade fever

3. Rovsing's sign

4. Obturator sign

5. Psoas sign

6. McBurney's point

7. Rebound tenderness

1. Distention

2. Increased intralumen pressure

3. Venous engorgement

4. Impaired arterial supply

5. ISCHEMIA

Appendicitis:

Dx

Tx

Dx:  Increased WBC, Urinalysis, CT, US, CXR

Tx:  Pre-op IV fluids & ABX

Laparscopy-non perforated

Perforated: IV fluids, PROMPT APPENDECTOMY, pus drainage, wound is left open to heal by secondary intent

Signs of inflammatory response:

Immature neutrophils (bands)

Today many call more than 80% of WBCs as neutrophil shift

Hernias:

Definition

Predisposing factors

Definition:

Protrusion of peritoneal sac thru musculoaponeuritic barrier- abdominal wall OR  fascia defect

Predisposing factors:

Increased in abdominal pressure-straining during defecation/urination

Obesity

Pregnancy

Ascites

abnormal congenital  anatomic route

Swollen of Fixed w/ in hernia sac

May cause intestinal obstruction, not reducible

Incisional Hernia

Hernia that comes thru an incision

This type of hernia is results due to:

Lack of obliteration of the process vaginalis during development and is congenital

This type of hernia results from:

any manuever that increases intrabdominal pressure

Most common hernias in both sexes and all ages??

Most common in elderly??

Most common in women??

Most common hernias in both sexes and all ages??

Indirect

Most common in elderly??

Direct

Most common in women??

Femoral

What type of Hernia are postitioned by the Hasselbach's triangle:

Lateral

With in

Lateral:  Indirect Inguinal

With in:  Direct Inguinal

This hernia is bound:

anteriorly by iliopubic tract and inguinal ligament

posteriorly by Cooper's ligament

lateral by femoral vein

Anteriorly:  Epigastric vessels

Lateral:  Inguinal ligament

Medial:  Rectus sheath lateral border

Floor:  Internal Oblique and Transverse abdominis muscle

1.Skin

2. Subcutaneous fat

3. Scarpa's fascia

4. External oblique muscle

5. Internal oblique muscle

6. Transverse abdominus muscle

7. Transversalis fascia

8. Preperitoneum fat

9.  Peritoneum

All 3 muscle layer aponeuroses from the anterior rectus sheath  and the posterior rectus sheath is not present below the arcuate line

Numbness in inner thigh or lateral scrotum

Will go away in 6 months

1. Vas deferens

2. Testicular artery

3.  Testicular pampiform venous plexus

4. Cremaster muscle fibers

5.  Genital branch of genitofemoral nerve

???

Sx:  abdominal distention

crampy abdominal pain

N, V

Obstipation

Common causes:  Ca, scarring d/t Diverticulitis, Volvolus

Tx of Large bowel obstruction??

Initial

Post

1.  Emergency laparotomy acute BO

2. Laparotomy w/ resection & diverting colostomy

3. Fiberoptic colonscopy w/ decompression

Post-op:

IV fluids

NG tube

Observe for complications

??

sx:  sharp, crampy, umbilical pain

N, V, Billious vomitting

Abdominal distention

Constipation

Bloody BM

common cause:  adhesions from surgery

NPO

NGT

IV fluids

Foley

Operative: 

Bowel resection

Laparotomy & Lysis of adhesions

Paralytic ileus:  AXR reveals gas thru out, including colon

No Bowel sounds-SILENT

SBO:  Bowel sounds PRESENT

Gas in the bowel wall/portal vein

Abdominal free air

Inflammation/Infection of the Gall Bladder

Female

Forty

Fat

Fertile

Flatulence

??

RUQ pain/tenderness

R subscapular pain

R referred should pain

Fever

N/V

+ Murphy's sign

Palpable gallbladder

??

sx:  episodic RUQ pain

Colicky

Often post prandial

Radiates to-back, R shoulder & scapula

Food intolerance-greasy/fatty

Dyspepsia

N/V

Cholelithiasis

sx are produced when the gall stones obstruct the flow of bile from:

gall bladder OR bile duct into intestines

??

LLQ pain

Fever

Altered bowel habits

urinary urgency

occasional palpable mass

Involves the colon mucosa & submucosa

Diverticulitis

Outpouching of the colon that are inflammed

Mild:  out-pt

clear liquids

broad spectrum ABX 7-10 days

Severe:  complete bowel rest

IV fluids

narcotics for pain

broad spectrum ABX

then: clear liquids in 48 hrs

high fiber diet in 1 wk

4-6 wks Colonscopy

By Ligament of Treitz

Before the ligament=Upper bleed

After the ligament=Lower bleed

Causes of:

Upper GI bleed

Lower GI bleed

Upper GI bleed:

Esophagitis

Varices

Gastric erosions

PUD

Neoplasms

Lower GI bleed:

Diverticula

AV malformation

Polyps

Hemorroids

Rectal Ca

Fistulas

Melena

Hematochezia-BRBPR

Hypovolumea d/t hemorrhage-pallor, weak, tachy, dizzy

ABC, VS

2 Large bore IV

T&C-correct coaguabilities

Upper:  Endoscopy

Lower:  Surgery