VASCULAR
AAA - ABDOMINAL AORTIC ANEURYSM
Stem- collapse + Abdo or back pain
PromptBack pain + shock
ResponseAAA 8cm
Likely to be a bleed into the wall as well (Clotted blood appears bright on ultrasound)
Intraluminal clot - suggestion of rupture (Say both in your answer seems to be a trend)
Note: Mural = attached to wall, Intraluminal = within vessel attached to wall ?interchangeable terms
Dx = ruptured AAA
DDx include all other causes of shock and back pain (eg: Pyelo with sepsis) with a coincidental (unruptured) AAA
Likely to be a bleed into the wall as well (Clotted blood appears bright on ultrasound)
Intraluminal clot - suggestion of rupture (Say both in your answer seems to be a trend)
Note: Mural = attached to wall, Intraluminal = within vessel attached to wall ?interchangeable terms
Dx = ruptured AAA
DDx include all other causes of shock and back pain (eg: Pyelo with sepsis) with a coincidental (unruptured) AAA
PromptOther important ultrasound findings
ResponseSuprarenal vs infrarenal on longitudinal view - requirement for suprarenal cross clamp in OT - greater morbidity
Free fluid in peritoneum - Indicates massive blood loss from rupture and more urgent OT
Free fluid in peritoneum - Indicates massive blood loss from rupture and more urgent OT
PromptConsiderations that would influence decision to do a CT
ResponseHaemodynamic status - dangerous to transport a shocked patient to the CT scanner
Proximity to CT - more ability iif CT is in the resus room
Pre-surgical planning requirement - placing stent requires good knowledge of pathology/anatomy - CT required for stent (vs open probably not needed)
Patient characteristics that may suggest palliation is the only suitable management.
Proximity to CT - more ability iif CT is in the resus room
Pre-surgical planning requirement - placing stent requires good knowledge of pathology/anatomy - CT required for stent (vs open probably not needed)
Patient characteristics that may suggest palliation is the only suitable management.
PromptRole of CT in unstable AAA
ResponseDependent on centre and established practice of vascular team
If AAA repair done by endovascular approach a CT is essential for planning/sizing of stent (even if risk of death in CT)
If AAA repair is done by open laparotomy, a CT scan is effectively contraindicated as it delays OT - this should be explained to vascular reg +/- consultant
Pros: anatomy - suprarenal vs infrarenal for operative planning, suitability of stent vs open
Cons: Time in CT=deterioration=death, Contrast load for kidneys (already about to have interrupted blood supply in OT)
If AAA repair done by endovascular approach a CT is essential for planning/sizing of stent (even if risk of death in CT)
If AAA repair is done by open laparotomy, a CT scan is effectively contraindicated as it delays OT - this should be explained to vascular reg +/- consultant
Pros: anatomy - suprarenal vs infrarenal for operative planning, suitability of stent vs open
Cons: Time in CT=deterioration=death, Contrast load for kidneys (already about to have interrupted blood supply in OT)
PromptResuscitation of ruptured AAA in preparation for theatre
ResponseImmediate referral to vascular surgeon for management
Prepare for OT - Urgent cross match/platelets/FFP (Will be required in OT)
Permissive hypotension SBP >80-90 (enough to perfuse the brain), resuscitation with blood only
Analgesia - Small aliquots of IV morphine/25mics boluses fentanyl titrated to pain
Urgent OT (Consider CT in conjunction with Vascular surgery. Plan should be OT immediately after)
Explaination to patient and family - high mortality
Prepare for OT - Urgent cross match/platelets/FFP (Will be required in OT)
Permissive hypotension SBP >80-90 (enough to perfuse the brain), resuscitation with blood only
Analgesia - Small aliquots of IV morphine/25mics boluses fentanyl titrated to pain
Urgent OT (Consider CT in conjunction with Vascular surgery. Plan should be OT immediately after)
Explaination to patient and family - high mortality
PromptDefinitive options for management of ruptured AAA
ResponseOT - open repair
Endovascular stent
Palliation
Endovascular stent
Palliation