acute limb ischemia - ESVS 2020 guideline
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This document summarizes the 2020 European Society for Vascular Surgery guidelines for the treatment of acute limb ischemia. It defines acute limb ischemia as a sudden decrease in arterial blood flow to the limb that threatens limb survival, requiring urgent evaluation and management within 2 weeks. The guidelines discuss the common causes of acute limb ischemia, diagnostic criteria including the 6 Ps signs, imaging options, classification systems for severity, and treatment approaches including open revascularization, thrombolysis, endovascular techniques, and postoperative management. Complications like compartment syndrome and reperfusion injury are also covered.
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Acute limb ischemia
1. Acute limb ischemia (ALI) occurs due to sudden deterioration of arterial blood supply to the limb. The main causes are thrombosis from atherosclerosis or embolism from cardiac sources.
2. ALI is clinically evaluated and classified into 3 classes based on severity of symptoms. Treatment depends on the class and involves early heparinization, catheter-directed thrombolysis, percutaneous thrombectomy, or surgical thrombectomy/bypass.
3. For less severe class I and IIA ALI, endovascular options like catheter-directed thrombolysis or pharmacomechanical thrombectomy are preferred to rapidly restore blood flow while minimizing risks. More severe class III ALI often requires emergency surgical intervention or
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Chronic total occlusion (CTO)
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
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Acute limb ischemia is a sudden interruption of blood flow to a limb that requires prompt diagnosis and treatment to prevent tissue death. It is commonly caused by arterial embolism or thrombosis. Clinical signs include the six Ps: pain, pallor, paresthesia, pulselessness, poikilothermia, and paralysis. Diagnosis involves Doppler ultrasound, angiography, and investigating for potential causes such as cardiac problems. For reversible ischemia, treatment involves anticoagulation, thrombolysis, or surgical embolectomy/thrombectomy. Irreversible ischemia requires amputation to prevent limb and life-threatening complications. Prompt diagnosis and treatment of the underlying cause are crucial to limb salvage.
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1) Aortic dissection is a tear in the inner layer of the aorta that allows blood to flow between the layers of the aortic wall, creating a false passageway. It was first documented in King George II of England in 1760.
2) Symptoms include a sudden, severe chest pain that can radiate to the back. Diagnosis is often challenging, but can be made through imaging like CT, MRI, or TEE ultrasound.
3) Type A dissections involving the ascending aorta require emergency surgery, while Type B dissections of the descending aorta can sometimes be treated medically to reduce blood pressure. Without treatment, mortality is high within the first few weeks.
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An aortic dissection occurs when blood tears the inner layer of the aorta, separating it from the middle layer. It is classified by location and timing of symptoms. Risk factors include hypertension, connective tissue disorders, and family history. Treatment depends on location but may include surgery, endovascular stent grafting, or medical management of blood pressure. Prognosis depends on type and treatment, with mortality rates declining with advances in surgical and endovascular techniques.
Acute limb ischemia
1. Acute limb ischemia is a medical emergency that occurs when there is a sudden decrease in blood flow to a limb, threatening the viability of the limb. It requires urgent evaluation and management within 2 weeks of symptom onset.
2. The main treatment options are endovascular therapies like catheter-directed thrombolysis or mechanical thrombectomy, or surgical interventions like thrombectomy or bypass surgery. The goal is to rapidly restore arterial blood flow while minimizing risks to the patient.
3. Factors like the severity of ischemia, time since symptom onset, and patient characteristics help determine which treatment - thrombolysis, surgical thrombectomy, or in some cases immediate amputation - is most appropriate to salvage the limb.
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The document discusses techniques for peripheral angiograms and potential complications. It covers operating room preparation including equipment such as needles, guide wires, sheaths, and catheters. Access site selection is discussed including the common femoral, popliteal, tibial, brachial, subclavian, and radial arteries. The angiogram procedure is outlined including artery puncture, sheath placement, guidewire insertion, catheter selection, contrast injection, and closure techniques such as manual compression or closure devices. Complications from the procedure are also mentioned.
Chronic total occlusion (CTO)
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
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Acute limb ischemia is a sudden interruption of blood flow to a limb that requires prompt diagnosis and treatment to prevent tissue death. It is commonly caused by arterial embolism or thrombosis. Clinical signs include the six Ps: pain, pallor, paresthesia, pulselessness, poikilothermia, and paralysis. Diagnosis involves Doppler ultrasound, angiography, and investigating for potential causes such as cardiac problems. For reversible ischemia, treatment involves anticoagulation, thrombolysis, or surgical embolectomy/thrombectomy. Irreversible ischemia requires amputation to prevent limb and life-threatening complications. Prompt diagnosis and treatment of the underlying cause are crucial to limb salvage.
Aortic dissection Nightmare
1) Aortic dissection is a tear in the inner layer of the aorta that allows blood to flow between the layers of the aortic wall, creating a false passageway. It was first documented in King George II of England in 1760.
2) Symptoms include a sudden, severe chest pain that can radiate to the back. Diagnosis is often challenging, but can be made through imaging like CT, MRI, or TEE ultrasound.
3) Type A dissections involving the ascending aorta require emergency surgery, while Type B dissections of the descending aorta can sometimes be treated medically to reduce blood pressure. Without treatment, mortality is high within the first few weeks.
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An aortic dissection occurs when blood tears the inner layer of the aorta, separating it from the middle layer. It is classified by location and timing of symptoms. Risk factors include hypertension, connective tissue disorders, and family history. Treatment depends on location but may include surgery, endovascular stent grafting, or medical management of blood pressure. Prognosis depends on type and treatment, with mortality rates declining with advances in surgical and endovascular techniques.
Acute limb ischemia
1. Acute limb ischemia is a medical emergency that occurs when there is a sudden decrease in blood flow to a limb, threatening the viability of the limb. It requires urgent evaluation and management within 2 weeks of symptom onset.
2. The main treatment options are endovascular therapies like catheter-directed thrombolysis or mechanical thrombectomy, or surgical interventions like thrombectomy or bypass surgery. The goal is to rapidly restore arterial blood flow while minimizing risks to the patient.
3. Factors like the severity of ischemia, time since symptom onset, and patient characteristics help determine which treatment - thrombolysis, surgical thrombectomy, or in some cases immediate amputation - is most appropriate to salvage the limb.
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Intravascular ultrasound (IVUS) uses sound waves to visualize the inside of arteries. There are two types of IVUS systems - mechanical systems using a rotating internal cable and solid-state systems using externally mounted transducers. Both produce 360-degree images with a resolution of 100-150 μm. IVUS is used to assess plaque, vessel dimensions, stent deployment, and more. It produces cross-sectional images showing the lumen, layers of the artery wall, and plaque composition and size. Measurements include diameters, areas, plaque burden, and indices of eccentricity. IVUS helps identify vulnerable plaque and has diagnostic and interventional applications.
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Coronary microvascular disease (CMVD), also known as cardiac syndrome X, can present with chest pain despite normal coronary arteries. It is classified into several types depending on whether structural heart disease is present. CMVD may be caused by abnormalities in the coronary microcirculation that lead to localized myocardial ischemia. Diagnosis involves stress tests showing ischemia without contractile abnormalities. Treatment focuses on lifestyle modification, medications like calcium channel blockers and ranolazine, and alternative therapies for pain management. In rare cases of microvascular "variant angina", coronary microvascular spasm can cause transient ST elevation resembling epicardial coronary spasm.
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Abdominal Aortic Aneurysm
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This document discusses acute aortic syndrome (AAS), which includes acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. AAS is caused by disruption of the aortic wall layers from tears or ulcers, allowing blood to track within the layers. The most common type is aortic dissection, where blood passes through a tear separating the vessel layers. Presenting symptoms typically include sudden severe chest or back pain. Diagnosis involves imaging like CECT, MRI, or TEE to identify abnormalities. Prognosis depends on factors like involvement of the ascending aorta and complications. Classification systems differentiate type A dissections involving the ascending aorta from type B.
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Bifurcation stenting
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Cardiogenic shock is a major cause of death in AMI patients and requires immediate diagnosis and management. The document outlines the definition, causes, predictive indicators, medical and interventional management of cardiogenic shock. It recommends emergency revascularization with PCI or CABG for suitable patients irrespective of time delay from MI onset. For those unsuitable for revascularization, fibrinolytic therapy is recommended if no contraindications. Intra-aortic balloon pump can be useful for hemodynamically unstable patients while alternative devices may be considered for refractory shock.
Dcm case presntatn vkas
This document presents the case of a 53-year-old female admitted with a fractured left distal radius from a bicycle fall. She has a history of dilated cardiomyopathy and heart failure. Her echocardiogram showed dilated left ventricle, global hypokinesia, and left ventricular ejection fraction of 27%. She underwent an ultrasound-guided supraclavicular brachial plexus block with minimal intravenous fluids for her fracture repair, which was uncomplicated. The discussion covers dilated cardiomyopathy, signs and symptoms, diagnostic studies, anesthetic concerns, and optimization for surgery. Brachial plexus anatomy and the supraclavicular approach are also described.
Physiological basis of coronary revascularisation
This document discusses the physiological basis of coronary revascularization. It covers topics such as coronary physiology, myocardial viability assessment, and coronary revascularization. Some key points include:
- Coronary blood flow is proportional to perfusion pressure over resistance and is regulated by various metabolic and endothelial factors.
- Myocardial ischemia occurs when oxygen demand exceeds supply. Coronary autoregulation and flow reserve help maintain adequate flow.
- Myocardial viability refers to dysfunctional tissue with limited scarring that has potential for functional recovery after revascularization through mechanisms like stunned myocardium and hibernation.
- Various techniques can assess viability including cardiac imaging and evaluating improvement in function after revascularization. Viability assessment aids decisions about revascularization
Peripheral vascular diseases
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, endovascular or surgical revascularization techniques, and exercise therapy. For intermittent claudication, cilostazol is an effective pharmacotherapy that improves walking distance. Acute limb ischemia requires immediate anticoagulation and revascularization to prevent limb loss.
Dilated cardiomyopathy
Dilated cardiomyopathy is defined as dilatation and impaired contraction of the left ventricle not caused by ischemic or valvular heart disease. The document discusses the epidemiology, etiology, pathology, genetics, clinical features, diagnosis, and management of idiopathic dilated cardiomyopathy. Key points include:
- The annual incidence is 5-8 per 100,000 people with increased risk in males, blacks, and those with hypertension or chronic beta-agonist use.
- Causes include genetic mutations, viral infections, autoimmune diseases, and drugs. Pathology shows dilatation, myocyte hypertrophy and death, and extracellular matrix remodeling.
- Diagnosis involves ECG
Dilated cardiomyopathy
Dilated cardiomyopathy is defined as dilatation and impaired contraction of the left or both ventricles not solely caused by abnormal loading conditions or ischemic heart disease. It has an annual incidence of 5-8 per 100,000 people and is more common in males, blacks, and those with hypertension or chronic beta-agonist use. Causes include genetic mutations, viral or autoimmune myocarditis, toxins, and metabolic abnormalities. On pathology, it shows cardiac dilatation and loss of myocytes leading to decreased wall thickness and increased fibrosis. Treatment involves managing heart failure symptoms and its underlying causes. Prognosis depends on factors like functional classification, ejection fraction, and biomarkers, with some patients experiencing improvement or stabilization
Shock
This document provides information on shock, including its definition, types, pathophysiology, clinical features, and management. It defines shock as a state of inadequate tissue perfusion and oxygenation that can lead to organ dysfunction and death. The main types of shock discussed are hypovolemic, septic, and cardiogenic shock. For each type, the document outlines their pathophysiology, signs and symptoms, and general management approach. Overall, it serves as an overview of shock for medical students, covering the essential details of definitions, types, effects on organ systems, and clinical distinctions between compensated and decompensated states of shock.
peripheralvasculardiseases-210612154006 (1).pptx
Peripheral vascular diseases (PVD), also known as peripheral artery occlusive disease, refers to obstruction or deterioration of arteries other than those supplying the heart or brain, primarily caused by atherosclerosis. PVD presents as either chronic arterial insufficiency or acute arterial occlusion. Management involves risk factor modification, exercise therapy for intermittent claudication, and endovascular or surgical revascularization depending on severity. For acute limb ischemia, the initial goals are to prevent thrombus propagation through anticoagulation and consider endovascular thrombolysis or surgical embolectomy to restore blood flow.
Cabg indications, conduits and results
This document discusses coronary artery bypass grafting (CABG), including indications, conduits used, and postoperative results. CABG is indicated for ischemic heart disease to relieve symptoms and improve survival. Common conduits are the internal thoracic artery, radial artery, and saphenous vein. Postoperative complications can include bleeding requiring reexploration (2-6% of cases), perioperative myocardial infarction (2-10% of first time CABG), neurologic events like delirium (30-80% at discharge), and stroke (incidence of 1-3%). Long-term patency of conduits is highest for the internal thoracic artery at 10 years.
Rhabdomyolysis
Rhabdomyolysis is the breakdown of skeletal muscle fibers that results in the release of muscle contents into the bloodstream. This can lead to acute kidney injury through deposition of myoglobin casts in the renal tubules. Treatment involves aggressive fluid resuscitation to prevent renal failure, treatment of hyperkalemia, and alkalinization of urine to prevent tubular obstruction. While bicarbonate and mannitol are commonly used, evidence does not clearly support their benefit over fluid resuscitation alone. Oxygen therapy and antioxidants may help reduce muscle injury. Dialysis may be needed for severe cases with refractory acidosis or hyperkalemia.
Shock
Shock is caused by inadequate systemic oxygen delivery that activates autonomic responses to maintain circulation. The main types of shock are hypovolemic, septic, cardiogenic, anaphylactic, neurogenic, and obstructive. Treatment focuses on airway control, oxygen delivery, circulation optimization through fluid resuscitation, and achieving hemodynamic goals to restore tissue perfusion. Early goal directed therapy for septic shock involving aggressive fluid administration and inotropes improves outcomes.
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.
A review of different types of shock encountered in patients. Hypovolemic, septic, cardiogenic and neurogenic shock. We review etiology, pathophysiology, diagnosis, treatment and how to differentiate between them.
Stressechocardiography
Stress echocardiography uses ultrasound imaging during exercise or pharmacologic stress testing to detect ischemia-induced changes in heart wall motion. It has several advantages over nuclear stress testing including better visualization of cardiac structures and no radiation exposure. Various stress agents can be used including exercise, dobutamine, dipyridamole, and adenosine. Detection of new or worsening wall motion abnormalities or improvement after revascularization indicates viable myocardium. Factors like image quality, timing of acquisition, and operator experience can impact test sensitivity. Stress echo is an established technique for diagnosing coronary artery disease and assessing myocardial viability.
Stress echocardiography
Stress echocardiography uses ultrasound imaging during exercise or pharmacologic stress testing to detect ischemia-induced changes in heart wall motion. It has several advantages over nuclear stress testing including better visualization of cardiac structures and no radiation exposure. Various stress agents can be used including exercise, dobutamine, dipyridamole, and adenosine. Detection of new or worsening wall motion abnormalities or improvement after revascularization indicates viable myocardium. Factors like image quality, timing of acquisition, and operator experience can impact test sensitivity. Stress echo is an established technique for diagnosing coronary artery disease and assessing myocardial viability.
Perioperative AKI-Shi Danni-20240119.pptx
The document discusses acute kidney injury (AKI) in the perioperative period. It defines AKI according to the KDIGO guidelines and outlines the epidemiology, risk factors, mechanisms, and outcomes of perioperative AKI. The risk factors include patient comorbidities, type of surgery, intraoperative hypotension or nephrotoxic medications. The mechanisms involve hypoperfusion, venous congestion, inflammation and nephrotoxicity. Outcomes of perioperative AKI include higher mortality, longer hospitalization and increased risk of chronic kidney disease. The document recommends renoprotective strategies like fluid management, hemodynamic control, avoidance of nephrotoxins and remote ischemic preconditioning to prevent perioperative AK
TREAD MILL TESTING.pptx
1) Exercise stress testing is used to detect myocardial ischemia through monitoring changes in the ECG and physiological parameters during exercise.
2) Key parameters include heart rate, blood pressure, oxygen consumption and the presence of ECG changes like ST segment depression or elevation.
3) Abnormal responses include inadequate heart rate or blood pressure increase, chest pain, significant ST changes and ventricular arrhythmias, which can indicate coronary artery disease.
Similar to acute limb ischemia - ESVS 2020 guideline (20)
MANAGEMENT OF ANTERIOR WALL MI WITH SHOCK IN A NON PCI CENTER
MANAGEMENT OF ANTERIOR WALL MI WITH SHOCK IN A NON PCI CENTER
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.
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chronic venous disease: in brief
Chronic venous disease (CVD) refers to abnormalities of the venous system that are long-lasting in nature and may cause signs or symptoms. CVD ranges from varicose veins to more advanced chronic venous insufficiency. Risk factors include age, female sex, obesity, prolonged standing, family history, and parity. The venous system consists of superficial veins like the great saphenous vein and deep veins like the femoral vein. Pathophysiology involves valve incompetence and reflux in the superficial system and obstruction or reflux in the deep system. Clinical presentation varies but includes heaviness, aching, cramps, and skin changes classified from C1 to C6. Investigation involves duplex ultrasound scanning and treatment options range from compression
Abdominal Vascular Injury - FB: Happy Friday Knight
1. Abdominal vascular injuries can be lethal due to hemorrhage. Management may include non-operative, endovascular, or operative approaches.
2. Blunt injuries often cause retroperitoneal hematomas in four zones, while penetrating injuries usually require opening the hematoma.
3. Most arterial injuries can be repaired, while venous injuries can often be ligated if extensive, with monitoring for sequelae.
Trauma of PANCREAS
The document discusses trauma to the pancreas. It begins with an overview of pancreatic anatomy and mechanisms of injury. It then describes the clinical presentation and methods for diagnosis of pancreatic trauma, including CT, MRCP, and ERCP. The document outlines a proposed revised grading system for pancreatic injuries from Grade I to V. It concludes with a discussion of management strategies depending on the grade of injury, including expectant management, surgery such as distal pancreatectomy or pancreaticoduodenectomy, and complications.
Trauma of duodenum
1) Duodenal trauma can present during laparotomy or be detected on CT scans. Isolated duodenal hematomas may be managed non-operatively with NG tube and TPN.
2) Operative procedures for duodenal trauma include duodenal repair and ancillary procedures like periduodenal drainage and feeding jejunostomy.
3) Complications include duodenal fistula and increased morbidity with major vascular injury, pancreatic injury, or injury-operation delay over 24 hours. Overall mortality is usually due to major vascular injury and ranges from 5-30%.
Breast Cancer Overview
Breast cancer is a disease where breast cells grow out of control, and is one of the leading causes of cancer death in women. Screening methods include mammography and ultrasound to check for abnormalities. The diagnosis involves a history, physical exam, imaging tests, and pathology to determine the stage. Treatment depends on the stage and includes surgery such as mastectomy or lumpectomy, radiation therapy, and systemic therapies like chemotherapy, hormone therapy, or targeted drugs.
How to Interpret CT Brain in TBI.pptx
This document provides information about the anatomy of the scalp and skull, including the layers of the scalp and the structures underneath. It also references sources that describe the brain's ventricular system and how to interpret CT scans of the brain, noting some types of injuries that may appear such as epidural hematoma, subdural hemorrhage, subarachnoid hemorrhage, cerebral contusions, and intracerebral hemorrhages.
C spine trauma
Cervical spine trauma can cause serious injuries to the vertebrae and spinal cord. A general surgeon provides an overview of cervical spine anatomy and classifications of injuries. Key points include that the cervical spine is made up of 7 vertebrae and has significant lordosis. Injuries are evaluated based on clinical exam, imaging, and stability classifications. Common injuries discussed are craniovertebral junction injuries, axis fractures, and subaxial cervical injuries. Initial management focuses on immobilization and identification of neurological deficits, while treatment depends on the injury and stability. Complications include spinal cord injury, which can impact respiratory and cardiovascular function.
Initial assessment in trauma
1. The document outlines the steps for the primary and secondary survey in the initial assessment of a trauma patient. It includes assessing the airway, breathing, circulation, disability, and exposure (ABCDE) and describes adjuncts like monitoring, imaging, catheter placement, investigations and treatments.
2. The primary survey involves a rapid assessment of life threats and stabilization, including airway management, breathing and ventilation, hemorrhage control, neurological assessment, and environmental control.
3. After initial stabilization, the secondary survey involves a full head-to-toe examination, gathering a medical history, considering transfer, and continued monitoring of the patient.
Head trauma for medical students
This document discusses common findings on CT brain scans related to various head injuries, including extradural hematoma (EDH), subdural hematoma (SDH), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and brain contusions. It provides details on the visual appearance and timing of injuries, such as EDH appearing lens shaped in the acute phase, SDH potentially associated with bridging veins tears, and chronic SDH displaying septations.
Trauma damage control
This document outlines damage control surgery techniques for trauma patients. Damage control surgery aims to control hemorrhage and contamination through limited operations, followed by intensive care resuscitation and reoperation. Specific techniques are described for the thorax, vasculature, liver, pancreas, spleen, and hollow viscera. Temporary abdominal closure is commonly used to prevent abdominal compartment syndrome before planned reoperation and definitive repair. Complications of open abdomen like fluid/protein loss and intestinal fistula require careful management.
Pelvic fractures made easy
This document provides an overview of pelvic fractures, including:
1. Classification systems for pelvic fractures including the Tile and Young-Burgess systems.
2. Diagnosis involves a history of traumatic injury and physical exam to check for signs of bleeding from the pelvis. Imaging of the pelvis is also used.
3. Management focuses on reducing pelvic volume to control bleeding through techniques such as pelvic binding, preperitoneal pelvic packing, external fixation, and angiographic embolization.
Common gastic problems for interns
This document provides an overview of common gastric problems for interns, including approaches to epigastric pain, alarm features in dyspeptic patients, and gastrointestinal evaluation of iron deficiency anemia. It discusses peptic ulcer disease, including causes, complications like bleeding and perforation, and treatment options. Evaluation of epigastric pain involves ruling out life-threatening conditions before considering treatments for conditions like gastritis. Endoscopy is recommended for dyspeptic patients with alarm features or risk factors for malignancy.
Medical monitoring system in Our Daily Life (Thai)
Monitoring the patient in a surgeon's aspect
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Venous thromboembolism
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and preventable cause of hospital death. VTE results from an interaction between venous stasis, hypercoagulability, and endothelial injury. Risk factors include advanced age, immobilization, surgery, trauma, cancer, and genetic or acquired thrombophilias. DVT presents with leg pain, swelling, and discoloration while PE causes shortness of breath, chest pain, and potentially cardiovascular collapse. Diagnosis involves D-dimer testing, ultrasound for DVT, and CT pulmonary angiography for PE. Treatment includes anticoagulation with heparin, low
Weaning ventilator
This randomized controlled trial compared two spontaneous breathing trial (SBT) strategies: a 2-hour T-piece trial versus a 30-minute trial with pressure support ventilation (PSV) of 8 cmH2O. The Kaplan-Meier curves showed a significantly higher rate of successful extubation, defined as being free of invasive ventilation for 72 hours, in the PSV group compared to the T-piece group. Reasons for reintubation were not significantly different between groups. While the T-piece SBT was less well tolerated, the PSV SBT of 30 minutes was sufficient to assess breathing ability without increasing post-extubation respiratory failure rates.
Variceal bleeding and massive upper gi bleeding
1) Variceal bleeding occurs in patients with cirrhosis and portal hypertension when enlarged veins in the esophagus or stomach (varices) rupture.
2) Management of variceal bleeding involves stabilizing the patient, performing endoscopy within 12 hours to identify varices, and administering vasoactive drugs to control bleeding along with antibiotics to prevent infection. Endoscopic variceal ligation or sclerotherapy can help stop active bleeding from varices.
3) For non-variceal upper GI bleeding, endoscopic treatment with adrenaline, coagulation, or clips is usually attempted first. Surgery may be needed for uncontrolled or recurrent bleeding after failed endoscopic attempts.
Head and cervical spine trauma
This document discusses guidelines for treating head and cervical spine trauma. The key points are:
1) The primary goals for head trauma are to prevent secondary brain injury through oxygenation and prompt transfer to a trauma center, with CT scans not delaying transfer.
2) Cervical spine injury must be considered in multiple trauma patients and immobilized to prevent neurological worsening. Indications for immobilization include altered mental status, spinal symptoms, or concerning mechanism of injury.
3) Imaging of the cervical spine depends on clinical decision tools, with CT preferred if available from occiput to T1; if CT is unavailable, plain films from these regions including swimmer's and odontiod views may be obtained initially.
Skin, soft tissue, and hand infection
This document provides information on various skin, soft tissue, and hand infections including severity classifications. It describes conditions like abscesses, folliculitis, furuncles, carbuncles, erysipelas, cellulitis, and necrotizing fasciitis. For necrotizing fasciitis, it emphasizes the need for aggressive and rapid treatment including emergent debridement and antibiotics to prevent high mortality rates. It also covers specific hand infections like paronychia, felon, pyogenic flexor tenosynovitis, and bursal infections.
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Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
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acute limb ischemia - ESVS 2020 guideline
- 1. FACEBOOK: HAPPY FRIDAY KNIGHT
- 2. ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES • definition: • Sudden decrease in arterial perfusion of the limb • Potential threat to the survival of the limb • Requiring urgent evaluation and management • Duration: < 2 weeks • Common causes • Embolism • Thrombosis of native arteries or reconstructions • Peripheral arterial aneurysm • Dissection • Traumatic arterial injury • Diagnosis • Medical emergency • 6Ps: late signs pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis • ABI < 0.7 is critical • Look for signs of visceral ischemia, neurosigns, and DVT • Cardiac exam to look for cardiac cause: AF • Imaging: DSA, duplex US, CE-MRA, and CTA (first line, most often used • Classification for severity: Rutherford Facebook: happy Friday knight
- 3. • Treatment • Initial • Oxygen therapy • UFH: 5000 U or 70-100 U/kg IV and monitor + adjust APTT ratio (aim: to reduce further embolism or clot propagation and provide anti-inflammatory effect • Adequate analgesia • Rehydration • Decision making • Open revascularization VS thrombolysis VS hybrid ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES • Open revascularization techniques • Thrombo-embolectomy • Using fogarty balloon • Under LA • Transverse arteriotomy if no plan to bypass • Surgical bypass • Used if intravascular recanalization not achieved • Used in acute on chronic ischemia • Vein graft VS prosthetic graft • Completion angiogram after surgery or embolectomy: recommend • If residual is found, intraarterial rtPA 4 – 10 mg directly into artery downstream Facebook: happy Friday knight
- 4. • Thrombolysis • Systemic: not recommend • Catheter directed thrombolysis (CDT) • Equivalent results to surgery • Initially used in IIA • Systematic review showed it may be used in Rutherford IIB • Access: femoral artery under US guide • Drugs: urokinase and rtPA (0.02 – 0.1 mg/kg/h) • Complications: • bleeding and access site • Distal embolization • Other endovascular techniques • Thrombus aspiration • Endovascular mechanical thrombectomy • Ultrasound accelerated thrombolysis ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES Facebook: happy Friday knight
- 5. COMPLICATIONS OF RESTORATION TO ISCHEMIC TISSUE: COMPARTMENT SYNDROME AND REPERFUSION INJURY • Tissue swelling in fascial compartment • Late diagnosis results in irreversible muscle necrosis and ischemic nerve damage • Dx: based on clinical symptoms and signs severely pain but can be minimal if nerve injury • Results: muscle damage myoglobin and CK leakage into circulation AKI • Compartment pressure: little consensus on threshold • Risk factors: duration > 6h, young, previous Hx of ALI, hypotension, high CK, severity, inadequate intraop backflow, positive fluid balance • Treatment: fasciotomy • Prevention: prophylactic fasciotomy after revascularisation • Postoperative treatment and follow up • Most common cause is AF and intracardiac thrombus prevention of recurrent embolization echo and CTA whole aorta if no cardiac source • For native arterial thrombosis • Look for concomitant malignancy or thrombophilia • Smoking cessation • Antithrombotic and statin recommend to decrease cardiac complication and to prevent atherosclerotic disease progression • Imaging: duplex US is modality of choice during follow up ACUTE LIMB ISCHEMIA – 2020 ESVS GUIDELINES Facebook: happy Friday knight