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Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
Aortic emergencies
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Aortic emergencies

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  • Pros 99% Sensitive Allows Operative Planning Fast Minimally Invasive Allows On-going Resuscitation Cons Misses Branch Vessels Requires Expertise May Miss Proximal Arch
  • Location: anywhere along the GI tract, most commonly the duodenum Very high mortality (60%) bleeding sepsis co-morbidity Dx: Clinical suspicion Clinical suspicion Clinical suspicion endoscopy angio CT (periaortic fluid)
  • Transcript

    • 1. A 66 year old man has had for threehours terrible “sharp-tearing”intrascapular back pain. At the time ofonset, he was lifting a heavy box. PMH; CAD,HTNBP 210/134 HR 118 RR 28 T 98.6He is in severe distress2/6 diastolic murmur
    • 2. A 72 year old female has over thepast 3 hours had severe aching leftarm pain.Exam: 144/76, 68, 36.4, 22Ashen left upper extremity with nopulsesRemainder of exam is normal A 62 year old male has the abrupt onset of urinary incontinence and weakness of both legs. He has had three days of thoraco-lumbar back pain. Exam: 184/98, 68, 36.8, 18 Normal other than flaccid and insensate lower extremities.
    • 3. AORTICEMERGENCIES Wayne Triner DO MPH FACEP Wanganui District Health Board State University of New York Albany Medical College
    • 4. The Normal Aorta From Aortic Annulus to Bifurcation Ascending Arch Descending Diameter 3cm to 2 cm. Numerous Ostea Intima, Media, Adventitia, Pericardium
    • 5. Thoracic Dissection 2.5 to 5 / 100,000 1/3 may go undiagnosed Risk Factors Hypertension Age Marfan’s Crack
    • 6. Pathogenesis of DissectionSeparation of layers within the media Initiating Event Intimal Tears Progression of Dissection Sheer forces
    • 7. Dissection Anatomy Location of Tear 60% Convexity of Sinus 10% Arch 30% descending Aorta
    • 8. Natural Course Ascending Descending (70% of all dissections) 70% chronicity 90% 72 hr mortality 10% operative (1-2%/hour) mortality 50% Aortic Regurg 10% medical 15% operative mortality mortality
    • 9. Diagnosis History 90% have pain Physical Exam Hypertension Shock Aortic Regurg Branch Vessel Occlusion d-dimer
    • 10. CXR Findings of DissectionWide MediastinumIncreased Aortic WallThicknessLeft Pleural EffusionMass Effect trachea NG tube left mainstem bronchus15% will have noabnormality
    • 11. Thoracic Aortic CT Angiogram
    • 12. TEE *
    • 13. Medical ManagementSheer Forces dp/dt dp dp dt dt
    • 14. Medical Management Analgesia Esmolol Nitroprusside LabatololStart in critical care setting (ED). If going to maintain on medical therapy, transition to oral within 24 hours of adequate control
    • 15. ManagementDecisions Time to Diagnosis Medical or Surgical Based upon classification – A or B Progression or impending rupture Branch vessel occlusion
    • 16. TEVAR
    • 17. A 63 year old male presents with sharp left flankand testicular pain of progressing severity over2 days. There has been no trauma, urethraldischarge, fever or scrotal swelling.BP 186/102, HR 108, RR 20, T98.2Abd: obese, mildly tender GU: non-tender, non-enlarged testicles normal scrotum, normal penis without dischargeU/A: 1+ HEMATURIA
    • 18. “Stone Protocol” CT
    • 19. Who, When Caucasian males Prevelance between 2% > 60 yo and 8% of men > 60 yo Family Hx More common in Maori Smokers (8.9 vs 3.7 per 100,000) ~ 15,000 US deaths from HTN rupture The Law of LaPlace 50% of ruptured AAAs survive to hospital 50% mortality for those reaching hospital
    • 20. ED Bedside Ultrasound Immediately available In “definitive” exams* Sens > 95% Spec > 95% Generally < 4 minutes
    • 21. A 62 year old male presents with severe sharp low back and flank pain of two hours duration with associated nausea and vomiting.BP 90/P, HR 124, RR 32, T 96.6pale, cool, diaphoretic, severe distressLungs CTA, HSRRRABD: pulsatile, tender large mass
    • 22. Misdiagnosis Most common misdiagnosis of AAA? Terrible sharp back pain Writhing on bed 60 year old male
    • 23. AAA Repair
    • 24. EndoVascularInfra-renal Aortic Repair (EVAR)
    • 25. Post Operative Complications ofAAA RepairEarly Late Everything bad Open Renal injury Aortoenteric Cord injury Fistula – Herald bleed Peri-op MI Distal emboli Graft Infection EVAR Endoleak Migration *
    • 26. Endograft Complications
    • 27. 85 yo female fell striking back.X-ray obtained for lumbar tenderness. A) Notify the OR and get a surgeon. B) Obtain an emergent uncontrasted CT. C) Have her seen in vascular clinic the next day. D) Give her an enema.
    • 28. At the End of the Day Basic Awareness Institutional Awareness Supportive Strategies Careful Planning

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