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TAEM10:Vascular emergency
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TAEM10:Vascular emergency

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นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี …

นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี
นพ.ประเสริฐ วศินานุกร

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  • 1.
          • PRASERT VASINANUKORN
          • PRASIT WUTHISUTHIMETHAWEE
          • SONGKLANAKARIND HOSPITAL
          • PSU, HATYAI, SONGKHLA
    VASCULAR EMERGENCY
  • 2. Scenario 1
    • ผู้ป่วยหญิงไทยคู่ อายุ 50 ปี
    • Refer มาจาก รพ . สตูลด้วยเรื่องขาทั้งสองข้างอ่อนแรง
    • 4 ชม . ก่อนไป รพ . สตูล (13.00 น .) ผู้ป่วยไปก้มๆเงยๆเก็บหอยแล้วมีอาการเจ็บหลังขึ้นมาทันที ร่วมกับมีขาทั้งสองข้างอ่อนแรงและชา จึงไป รพ . สตูล
    • Underlying: ญาติให้ประวัติว่าเป็นโรคหัวใจขาดเลือดมา 5 ปี ตรวจพบที่คลินิก แต่ไม่ต้องกินยา ???
    • No history of drug allergy
  • 3. Physical examination ( จาก รพ . สตูล )
    • V/S : BP 130/90 mmHg, PR 90/min
    • GA : consciousness
    • HEENT : not pale, no icteric sclera
    • Heart and Lungs : WNL
    • Abdomen : soft, not tender
    • Back : tender at L2-3 area, no stepping
  • 4. Physical examination ( จาก รพ . สตูล )
    • E4V5M6, pupil 2 mm BRTL
    • No facial palsy, EOM full
    • Motor Right Left
      • Upper V V
      • Lower 0 0
    • DTR Right Left
      • Upper 2+ 2+
      • Lower 0 0
  • 5. Physical examination ( จาก รพ . สตูล )
    • BBK : negative
    • Clonus : negative
    • Stiffness of neck : negative
    • Pinprick sensation : loss below L1 level
    • Sphinctor tone : loose
    • Bulbocavernosus reflex : negative
    • Eyeground : sharp disc
  • 6. Problem? Differential diagnosis Management?
  • 7.  
  • 8.  
  • 9. Scenario 2 ผู้ป่วยชายไทย 72 ปี ถูกนำส่งห้องฉุกเฉิน โรงพยาบาลสงขลานครินทร์ ด้วยเรื่อง ปวดท้องมาก ปวดหลัง และเป็นลม ระหว่างนั่งคอยตรวจเลือด เพื่อมา FOLLOW UP P.H. KNOWN HT, DM, SMOKER P.E. SEMICONSCIOUSNESS, NOT PALE PR 80 BP 100/80 RR 18 SAT 97%
  • 10. Scenario 2 CHEST - HEART O.K. ABD - SLIGHT TENDER - MILD GUARDING บริเวณ Rt. SIDE ABDOMEN & FLANK - NO DEFINITE MASS
  • 11. Problem? Differential diagnosis Management?
  • 12. Causes of Human Diseases PATHOLOGY : CONGENITAL, INFECTION, TRAUMA TUMOUR, DEGENERATIVE DISEASES NATURED : ENVIRONMENT, DISASTER MAN MADE : CRIME, WAR, SELF-INFLICT
  • 13. VASCULAR PATHOLOGY ARTERIAL ATHEROSCLEROSIS ART.OCCLUSION EMBOLI THROMOSIS DISSECTION ANEURYSM TRAUMA VENOUS PHLEBITIS VENOUS THROMBOSIS PULM. EMBOLISM A-V FISTULA TRAUMA VARICOSITIES
  • 14. VASCULAR EMERGENCY INVOLVE - ALL PART OF THE BODY - ALL SYSTEMS, ORGANS - SYMPTOMS & SIGN VARIES - SAME ACUTE ONSET-RAPID PROGRESS - SAME PATTERN OF PATHOPHYSIOLOGY
  • 15. VASULAR EMERGENCY TRAUMA NON-TRAUMA PENETRATING BLUNT IATROGENIC ARTERIAL OCCLUSION ATHEROSCEROSIS DISSECTION ANEURYSM VENOUS THROMBOSIS PULMONARY EMBOLISM ARTERIO-VENOUS FISTULA EMBOLI THROMBOSIS SPASM SUPERFICIAL DEEP V.
  • 16. VASCULAR EMERGENCY REQUIRE EARLY DIAGNOSIS AND MANAGEMENT ONLY 3-5 MINUTES WILL RESULT IN DISABILITY OR DEATH EARLY CONSULTATION AND TEAM APPROACH IS REQUIRED DETAIL KNOWLEDGE OF PARTICULAR DISEASE REQUIRED METHOD OF DIAGNOSIS AND TREATMENTS VARIED EP SHOULD KNOW ADVANTAGE AND DISADVANTAGE OF EACH EP SHOULD KEEP IN MIND IN EVERY PATIENTS VISITED ER
  • 17. COMMON VASCULAR EMERGENCY IN THAILAND (PERSONAL, 35 YRS, SINGLE VASC.SURGEON, 12 MILL.POP,14 PROVINCES) VASCULAR TRAUMA ARTERIAL OCCLUSION RUPTURED ABDOMINAL AORTIC ANEURYSM (AAA) CORONARY HEART DISEASES RUPTURED THORACIC AORTA – TRAUMATIC VENOUS THROMBOSIS – PULMONARY EMBOLISM
  • 18. COMMON VASCULAR EMERGENCY IN GENERAL CVA – TIA, STROKE CORONARY ARTERY DISEASES AORTIC DISSECTION RUPTURED AORTIC ANEURYSM THORACIC AORTIC TRAUMA
  • 19. COMMON VASCULAR EMERGENCY IN GENERAL PERIPHERAL VASCULAR TRAUMA MESENTERIC OCCLUSION PERIPHERAL ARTERIAL OCCLUSION VENOUS THROMBOSIS PULMONARY EMBOLISM
  • 20. MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMS SYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE CNS - TIA, STROKE CVS - CORONARY, DISSECTION, ANEURYSYM EMBOLISM, THROMBOSIS, VENOUS DIS. THORACIC - DISSECTION, RUPTURED, ANEURYSM
  • 21. MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMS SYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE ABDOMINAL - AAA, MESENTERIC OCCLUSION - AORTO-ILIAC OCCLUSION EXTREMITIES - EMBOLISM, THROMBOSIS VENOUS - DEEP VEIN THROMBOSIS, PULMONARY EMBOLISM
  • 22. PATHOPHYSIOLOGY(1): ARTERIAL OCCLUSION : EMBOLI ACUTE ON SET OF SYMPTOMS & SIGN (5Ps) PAIN PALLOR PARESTHESIA PARALYSIS PULSELESSNESS SOURCE – MI, MV with AF, HT ELDERLY MALE > FEMALE NORMAL COLOR SKIN NAIL HAIR IN OPPOSITE EXTREMITY RAPID ONSET SYMPTOMS & SIGNS
  • 23.  
  • 24. PATHOPHYSIOLOGY (2) : ARTERIAL OCCLUSION : THROMBOSIS PROGRESSIVE ONSET WITH ACUTE EXACERBATION PAIN PALLOR PARESTHESIA PARALYSIS PULSELESSNESS ELDERLY MALE > FEMALE ATHEROSCLEROSIS HT, DM, SMOKER, COPD ATROPHIC CHANGE SKIN, HAIR, NAIL BILAT EXT., EQUALLY INVOLVED
  • 25.  
  • 26.  
  • 27. DIAGNOSIS HISTORY, PHYSICAL EXAM., DOPPLER, EKG DOPPLER COLOUR ULTRASOND MRI – ANGIOGRAM CONVENTIONAL ANGIOGRAM EMERG : MANAGEMENT : HEPARIN 80 UNITS/Kg I.V.BOLUS MAINTENANCE 18 UNITS/Kg/HOUR EARLY SURGICAL CONSULTATION : FOGARTY EMBOLECTOMY SURGICAL BY PASS GRAFT, THROMBECTOMY
  • 28. FOGARTY EMBOLECTOMY
  • 29. MANIFESTATION BY PATHOLOGY ARTERIAL OCCLUSION : TIA, STROKE CAUSES BY EMBOLI – THROMBOSIS ACUTE ONSET – TRANSIENT RAPID PROGRESS DEFINITE NEUROLOGICAL DEFICIT UNDERLYING – ELDERLY, HT, DM CT SCAN, HEPARIN, ANTIPLATELET
  • 30. THORACIC AORTIC DISSECTION AND ANEURYSM TRAUMATIC RUPTURED OF THORACIC AND IT BRANCHES
  • 31.  
  • 32.
    • THORACIC AORTIC DISSECTION – MORTALITY 1%/HR.
      • MEDIAL NECROSIS OF AORTA, BICUSPID AORTIC VALVE
      • IN USA INCIDENCE 1-5 PER 100,000, TYPE A>B
      • 44% OF MARFAN SYNDROME , POST CARDIAC SURGERY 14%
      • COMMON ASSOCIATE SYMPTOM : HYPERTENSION, SMOKER
        • CHEST PAIN 73% WIDENING MED 62%
        • AI MURMUR 40% LV HYPERTROPHY 25%
        • NORMAL CXR 15% NORMAL EKG 30%
  • 33. SYMPTOMS & SIGNS
    • MIDLINE SUBSTERNAL CHEST PAIN
    • PULSE DEFICIT OR UNEQUAL
    • ELDERLY MAN HYPERTENSIVE
    • INVOLVED THORACIC ANEURYSM IN 30%
    • NO ANEURYSMAL DILATATION IN 70%
    • SOME PATIENT HAS NEUROLOGICAL DEFICIT
    • “ ACUTE SPINAL CORD SYNDROME”
  • 34. DIFFERENTIAL DIAGNOSIS – INVESTIGATION ACUTE MYOCARDIAL INFARCTION – EKG, TROP-T RUPTURE THORACIC AORTIC ANEURYSM, PE. POST PERICARDIOTOMY SYNDROME – PERICARDITIS BOERHAAVE’S SYNDROME : DYSPHAGIA, HEMATEMESIS INVESTIGATION : CXR, EKG, ECHO, TEE, CT, MRI
  • 35. EMERGENCY MANAGEMENT REDUCE B.P. TO 100 – 120 mmHg PR. TO 60 - 80 Morphine, BETA BLOCKER, NIROPRUSSIDE EARLY CONSULTATION CARDIOLOGIST SURGEON MORTALITY SURGERY 20% MEDICAL Rx. 56% OVERALL MORTILY IN HOSPITAL 30 – 40%
  • 36. VASCULAR EMERGENCY – THORACIC AORTIC & BRANCH BLUNT CHEST TRAUMA – SIDE, FRONT IMPACTED USUAL ASSOC WITH FRACTURE UPPER RIB, STERNUM SCAPULA, SHOULDER, CLAVICLE STEARING WHEEL IMPRINT, FLAIL CHEST MASSIVE HEMOTHORAX > 1500 cc, HYPOTENSIVE UNEQUAL BLOOD PRESSURE AND PULSE OF ARM MORTALITY AT THE SCENE > 30% (TRANSPORTATION)
  • 37. MEDIASTINAL CLUES FOR GREAT VV. INJURY OBLITERATION OF AORTIC KNOB WIDENING OF MEDIASTINUM > 8 cm. DEPRESSION OF LEFT MAIN BRONCHUS > 140 ° LOSS PERIVERTEBRAL PLEURAL STRIPE DEVIATION OF NASOGASTRIC TUBE
  • 38. INVESTIGATIONS CXR, PA – LAT. OBLIQUE, ECHOCARDIO. R/O CARDIAC INJ CT, MRI, DSI (DIGITAL SUBSTRACTION ANGIOGRAM) AORTOGRAM TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
  • 39. RUPTURE ANEURYSM – SUBCLAVIAN ACUTE NECK PAIN WITH OR WITHOUT STROKE HOARSENESS, NECK SWELLING AIR WAY OBSTRUCTION, EMBOLISATION DEVIATION OF TRACHEA ACUTE SVC OBSTRUCTION DYSPHAGIA RARE ONLY 1% OF PERIPHERAL ANEURYSM
  • 40.  
  • 41.  
  • 42. RUPTURED AAA AAA – DILATATION OF AORTA > 50% OF DIAMETER PREVALENCE 3 – 10% OF PATIENTS AGE OVER 50 PREVALENCE INCREASED BY : FAM HX, ELDERLY, MALE, SMOKING ROUTINE PHYSICAL EXAM : LOW SENSIVITY 29% (3 – 4 cm) 50% (4 – 5 cm) 76% (>5 cm ) MOST ASYMPTOMATIC ARE DETECTED INCIDENTALLY DURING USG FACTORS INCREASED RISK OF RUPTURE : HYPERTENSION SMOKING, COPD, FAMILY HISTORY
  • 43. DIAGNOSIS OF RUPTURED AAA 50% OF PT. ARE UNAWARE OF AAA PRESENT BEFORE SUDDEN ONSET OF ABDOMINAL OR BACK PAIN – HYPOTENSIVE TRANSIENT LOSS OF CONSCIOUS, ABDOMINAL MASS ULTRASONND FOR UNSTABLE OR R/O AAA CT FOR STABLE PATIENT RETROPERITONEAL RUPTURE 80% FREE PERITONEAL 20% MORTALITY FOR RUPTURED AAA 30 – 80%
  • 44. PROBLEMS OF SUPTURED AAA IN ER DIAGNOSIS : KNOWN AND UNKNOWN AAA RESUSCITATION : KEEP B.P. 90 – 100 mmHg IF BP < 80 DO NOT DELAYED IN ER PATIENT GO DIRECTLY TO OR RESUSCITATION ABDOMINAL PAIN – TENDER ANEURYSM OR ELDERLY – HYPERTENSIVE – ABD PAIN + MASS OR
  • 45.  
  • 46.  
  • 47. OTHER INTRA-ABDOMINAL ANEURIYSM
  • 48. PERIPHERAL ARTERIAL ANEURYSM FEMORAL POPLITEAL
  • 49. MESENTERIC OCCLUSION
  • 50. THANK YOU FOR YOUR ATTENTION
  • 51.