Professional Documents
Culture Documents
ABC!
Alert & conversational but in obvious pain.
History
SOCRATES Differentials tool
Skin shingles, trauma, burns, cellulitis, oedema Tissue bruising, swelling Blood vessels ischaemia, DVT, varicose veins Nerves compartment syndrome Muscles trauma, strain Ligaments/tendons sprain, rupture Bone fracture (pathological/non)
Pt c/o pain in lower left leg, sudden onset. Prior to this - claudication and rest pain for several weeks. What else is important in an ischaemic Hx? Rest pain, night pain, exercise tolerance and cardiovascular risk factors
Age Male Smoking Diabetes Cholesterol Hypertension FHx Ethnicity Obesity Other CV disease Erectile dysfunction!
6Ps of ischaemia
Look for ulcers Tissue loss (i.e. amputations) Scars (previous surgery) Buergers test/angle End pieces?
Patient brought to A&E Obese 68 year old man, severe abdo pain, pale, sweaty, very unwell What are you going to do??...
ABC!! A speaking to you B RR 30 shallow breathing, sats 85% on air C BP 75/42 (was 85/50 5 mins ago!), HR 125, cap refill 7secs D GCS 14/15 E tender, pulsatile abdomen What is going on and what do you do next?
Oxygen 15litres, non-rebreathe Wide bore cannula x2 Bloods: X match 4-8units, clotting, FBC, U&E, amylase Fluid resus colloid stat, keep systolic <100 TRANSFUSE CALL VASCULAR SURGEONS!
If his AAA had been discovered earlier what could have been done?
Normal size For surveillance, reduce CV risk factors Surgery recommended
5.5 cm
Venous Ulcer
Neuropathic ulcer
Arterial Ulcer
Arterial Site Distal, dorsum of foot/ toes Smaller Irregular borders Grey/blue
Neuropathic Pressure points Small Punched out Not always visible, foreign bodies present Deep sinus Painless
Other (Malignant) Anywhere, can be at site of other ulcers Increasing size Rolled/ hard & raised Necrotic and sloughy variable Painless
Larger Irregular Granulating tissue Shallow Can be painful Venous eczema, haemosiderin
Venous compression stockings (check ABPI first!), treat varicose veins Arterial revascularise, debride, reduce CV RFs Neuropathic diabetic control, good foot care, foreign body removal! Other biopsy & treat as per malignant dermatological condition
Risk factors? Occupations with prolonged standing, pregnancy, intra abdominal mass, obesity, age, female (x6 risk), previous DVT Examination what should you include?
Trendelenburgs test
Conservative compression stockings, lose weight, reduce standing! Surgical Sclerotherapy, laser therapy, High tie/ stripping
High pressure within a compartment of limb causing compromise to neurovascular supply Hx recent limb trauma/ surgery
Pain out of proportion to event
Examination
Pain on passive flexion
Investigation
Measure compartment pressures
Management
Fasciotomy
Dialysis Fistula
Aortic Dissection
Stanford Type A involves ascending aorta (DeBakey I & II) Type B Does not involve ascending aorta (DeBakey III)