นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี นพ.ประเสริฐ วศินานุกร

6. Problem? Differential diagnosis Management?

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

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

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

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

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

47. OTHER INTRA-ABDOMINAL ANEURIYSM

48. PERIPHERAL ARTERIAL ANEURYSM FEMORAL POPLITEAL

49. MESENTERIC OCCLUSION

50. THANK YOU FOR YOUR ATTENTION