PRASERT VASINANUKORNPRASIT WUTHISUTHIMETHAWEESONGKLANAKARIND HOSPITALPSU, HATYAI, SONGKHLA

Scenario 1• ผู้��ป่�วยหญิ�งไทยคู่�� อาย� 50 ป่�• Refer มาจาก รพ.สตู�ลด้�วยเร� องขาท"#งสองข�างอ�อนแรง• 4 ชม.ก�อนไป่ รพ.สตู�ล (1 3 .0 0น .) ผู้��ป่�วยไป่ก�มๆเงยๆเก(บหอยแล�วม*อาการเจ(บหล"งข+#นมาท"นท* ร�วมก"บม*ขาท"#งสองข�างอ�อนแรงและชา จ+งไป่ รพ.สตู�ล• Underlying: ญิาตู�ให�ป่ระว"ตู�ว�าเป่.นโรคู่ห"วใจขาด้เล�อด้มา 5 ป่� ตูรวจพบท* คู่ล�น�ก แตู�ไม�ตู�องก�นยา ???• No history of drug allergy

Physical examination (Physical examination (จาก รพจาก รพ..สตู�ลสตู�ล))

•V/S : BP 130/90 mmHg, PR V/S : BP 130/90 mmHg, PR 90/min90/min

•GA : consciousnessGA : consciousness•HEENT : not pale, no icteric HEENT : not pale, no icteric

sclerasclera•Heart and Lungs : WNLHeart and Lungs : WNL•Abdomen : soft, not tenderAbdomen : soft, not tender•Back : tender at L2-3 area, Back : tender at L2-3 area,

no stepping no stepping

Physical examination (จาก รพ.สตู�ล)

• 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

Physical examination (จาก รพ.สตู�ล)

• BBK : negative• Clonus : negative• Stiffness of neck : negative• Pinprick sensation : loss below

L1 level• Sphinctor tone : loose• Bulbocavernosus reflex :

negative• Eyeground : sharp disc

Problem?Problem?Differential diagnosis

ManagemenManagement?t?

Scenario 2ผู้��ป่�วยชายไทย 72 ป่� ถู�กน1าส�งห�องฉุ�กเฉุ�น โรงพยาบาลสงขลานคู่ร�นทร3 ด้�วยเร� อง ป่วด้ท�องมาก ป่วด้หล"ง และเป่.นลม ระหว�างน" งคู่อยตูรวจเล�อด้ เพ� อมา FOLLOW UP

P.H. KNOWN HT, DM, SMOKER

P.E. SEMICONSCIOUSNESS, NOT PALE

PR 80 BP 100/80 RR 18 SAT 97%

Scenario 2

CHEST - HEART O.K.

ABD - SLIGHT TENDER

- MILD GUARDING

บร�เวณ Rt. SIDE ABDOMEN & FLANK

- NO DEFINITE MASS

Problem?Problem?Differential diagnosis

ManagemenManagement?t?

Causes of Human

DiseasesPATHOLOGY : CONGENITAL, INFECTION, TRAUMA TUMOUR, DEGENERATIVE DISEASES

NATURED : ENVIRONMENT, DISASTER

MAN MADE : CRIME, WAR, SELF-INFLICT

VASCULAR PATHOLOGYARTERIAL

ATHEROSCLEROSIS

ART.OCCLUSION

EMBOLI

THROMOSIS

DISSECTION

ANEURYSM

TRAUMA

VENOUS

PHLEBITIS

VENOUS THROMBOSIS

PULM. EMBOLISM

A-V FISTULA

TRAUMA

VARICOSITIES

VASCULAR EMERGENCY

INVOLVE- ALL PART OF THE BODY

- ALL SYSTEMS, ORGANS

- SYMPTOMS & SIGN VARIES

- SAME ACUTE ONSET-RAPID PROGRESS

- SAME PATTERN OF PATHOPHYSIOLOGY

VASULAR

EMERGENCY

TRAUMA

NON-TRAUMA

PENETRATINGBLUNTIATROGENIC

ARTERIAL OCCLUSION ATHEROSCEROSIS DISSECTION ANEURYSM VENOUS THROMBOSIS PULMONARY EMBOLISM ARTERIO-VENOUS FISTULA

EMBOLITHROMBOSISSPASM

SUPERFICIALDEEP V.

VASCULAR EMERGENCYREQUIRE 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

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

COMMON VASCULAR EMERGENCY IN GENERAL

CVA – TIA, STROKE

CORONARY ARTERY DISEASES

AORTIC DISSECTION

RUPTURED AORTIC ANEURYSM

THORACIC AORTIC TRAUMA

COMMON VASCULAR EMERGENCY IN GENERAL

PERIPHERAL VASCULAR TRAUMA

MESENTERIC OCCLUSION

PERIPHERAL ARTERIAL OCCLUSION

VENOUS THROMBOSIS

PULMONARY EMBOLISM

MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMSSYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE

CNS - TIA, STROKE

CVS - CORONARY, DISSECTION, ANEURYSYM

EMBOLISM, THROMBOSIS, VENOUS DIS.

THORACIC - DISSECTION, RUPTURED, ANEURYSM

MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMSSYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE

ABDOMINAL - AAA, MESENTERIC OCCLUSION

- AORTO-ILIAC OCCLUSION

EXTREMITIES - EMBOLISM, THROMBOSIS

VENOUS - DEEP VEIN THROMBOSIS, PULMONARY

EMBOLISM

PATHOPHYSIOLOGY(1): ARTERIAL OCCLUSION : EMBOLIACUTE 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

PATHOPHYSIOLOGY (2) : ARTERIAL OCCLUSION : THROMBOSISPROGRESSIVE ONSET WITH

ACUTE EXACERBATIONPAIN

PALLOR

PARESTHESIA

PARALYSIS

PULSELESSNESS

ELDERLY MALE > FEMALE

ATHEROSCLEROSIS

HT, DM, SMOKER, COPD

ATROPHIC CHANGE SKIN, HAIR, NAIL

BILAT EXT., EQUALLY INVOLVED

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

FOGARTY EMBOLECTOMY

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

THORACIC AORTIC DISSECTION AND

ANEURYSM

TRAUMATIC RUPTURED OF THORACIC

AND IT BRANCHES

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%

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”

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

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%

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)

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

INVESTIGATIONS

CXR, PA – LAT. OBLIQUE, ECHOCARDIO. R/O CARDIAC INJ

CT, MRI, DSI (DIGITAL SUBSTRACTION ANGIOGRAM)

AORTOGRAM

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)

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

RUPTURED AAAAAA – 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

DIAGNOSIS OF RUPTURED AAA50% 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%

PROBLEMS OF SUPTURED AAA IN ERDIAGNOSIS : 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

OTHER INTRA-

ABDOMINAL

ANEURIYSM

PERIPHERAL ARTERIAL ANEURYSM

FEMORAL

POPLITEAL

MESENTERIC OCCLUSION