Cardiovascular Emergencies – Part II

Acute Aortic Dissection Uncommon but lethal! Uncommon but lethal! Tear in the intimal layer of the aorta that results in a false lumen that is usually anterograde in nature. Tear in the intimal layer of the aorta that results in a false lumen that is usually anterograde in nature. Usual locations: ascending aorta superior to aortic valve descending aorta at the ligamentum arteriosm

Acute Aortic Dissection Most common in men between the ages of 60 & 70 Most common in men between the ages of 60 & 70 Factors: Factors: hypertensionhypertension hereditary defects of connective tissue (Marfan’s)hereditary defects of connective tissue (Marfan’s) pregnancy pregnancy blunt trauma blunt trauma iatrogenic factors (intra-arterial catheterization) iatrogenic factors (intra-arterial catheterization)

Acute Aortic Dissection SUBJECTIVE DATA History History Pain – sudden, sharp, tearing, excruciating, medications may not relieve, substernal (ascending), back/flank (descending) Pain – sudden, sharp, tearing, excruciating, medications may not relieve, substernal (ascending), back/flank (descending) Syncope Syncope Altered LOC Altered LOC Paraplegia Paraplegia

Acute Aortic Dissection OBJECTIVE DATA Physical Exam Physical Exam - variable BPs on right vs left - variable BPs on right vs left - decreased peripheral pulses/ peripheral cyanosis - decreased peripheral pulses/ peripheral cyanosis - murmur - murmur - pallor, oliguria, altered LOC, - pallor, oliguria, altered LOC, - BP: hyper with distal dissection, hypo with proximal - BP: hyper with distal dissection, hypo with proximal - extreme pain - extreme pain

Acute Aortic Dissection OBJECTIVE DATA Diagnostics Diagnostics - CBC (Hct tends to fall, WBC - CBC (Hct tends to fall, WBC 12,000-20,000) 12,000-20,000) T&C,BUN/Creatinine T&C,BUN/Creatinine - EKG: - EKG: Normal in 1/3, LV hypertrophy if hx of HTN, signs of MI if proximal dissection -

Acute Aortic Dissection CXR: -widened aortic silhouette -widened aortic silhouette -widened mediastinum, -widened mediastinum, -left-sided pleural effusion -left-sided pleural effusion

Acute Aortic Dissection Diagnostics cont. Diagnostics cont. - CT Scan - CT Scan

Acute Aortic Dissection INTERVENTIONS ABC ABC Pain relief Pain relief Large bore IVs Large bore IVs – minimum of two sites– minimum of two sites Monitoring Monitoring Medications: Medications: 1)to lower arterial BP: nitroprusside, labetalol

Acute Aortic Dissection Medications cont: Medications cont: 2) To decrease contraction force: 2) To decrease contraction force: beta blockers preferred, may give calcium channel blockers if beta blockers contraindicated beta blockers preferred, may give calcium channel blockers if beta blockers contraindicated 3) To relieve pain: Morphine 3) To relieve pain: Morphine Position of comfort Position of comfort IVF in hypotensive setting IVF in hypotensive setting Foley Foley

Acute Aortic Dissection Anticipate: Anticipate: ED thoracotomy, immediate need for OR, arterial & central venous cannulation ED thoracotomy, immediate need for OR, arterial & central venous cannulation Therapeutics: Therapeutics: Explain all procedures to patient/family, maintain calm, Explain all procedures to patient/family, maintain calm, allow family at bedside if possible allow family at bedside if possible

Acute Pericarditis Result of inflammation of the pericardium that may extend to adjacent structures and may produce exudate. Result of inflammation of the pericardium that may extend to adjacent structures and may produce exudate. Factors: Factors: - infections: idiopathic, viral, bacterial, fungal - infections: idiopathic, viral, bacterial, fungal - connective tissue disease (lupus, rheumatoid) - connective tissue disease (lupus, rheumatoid) - renal disease - renal disease - neoplastic disorders - neoplastic disorders - tissue injury - tissue injury

Acute Pericarditis SUBJECTIVE DATA General malaise, fever, chills, weight loss General malaise, fever, chills, weight loss Dyspnea, cough Dyspnea, cough Chest Pain – deep inspiration, recumbent, movement, severe, sharp or dull ache, retrosternal or epigastric radiating to back/neck/ side, sudden, persistent Chest Pain – deep inspiration, recumbent, movement, severe, sharp or dull ache, retrosternal or epigastric radiating to back/neck/ side, sudden, persistent

Acute Pericarditis SUBJECTIVE DATA cont. Medical History may include: Medical History may include: TB, congenital anomalies, immune disorders, MI, neoplastic disease, drug use, uremia, cardiac surgery, cardiac trauma, infectionsTB, congenital anomalies, immune disorders, MI, neoplastic disease, drug use, uremia, cardiac surgery, cardiac trauma, infections

Acute Pericarditis OBJECTIVE DATA Physical Exam Physical Exam - pericardial friction rub (hallmark) – heard best - pericardial friction rub (hallmark) – heard best at the left lower sternum during end expiration at the left lower sternum during end expiration with patient leaning forward with patient leaning forward - tachycardia, fever, tachypnea - tachycardia, fever, tachypnea

Acute Pericarditis INTERVENTIONS Supplemental O2, cardiac Supplemental O2, cardiacmonitoring Position of comfort Position of comfort Anti-inflammatory medications Anti-inflammatory medications Pericardiocentesis if necessary Pericardiocentesis if necessary Labs as ordered Labs as ordered Antibiotics as ordered Antibiotics as ordered

Acute Pericarditis INTERVENTIONS cont Monitor/reassess Monitor/reassess Therapeutics: Therapeutics: maintain calmmaintain calm explain all proceduresexplain all procedures allow family at bedside if possibleallow family at bedside if possible reassurancereassurance

Infective Endocarditis Infection of the endocardium and heart valves SBE SBE subacute bacterial endocarditis usually occurs in patients with congenital or acquired valvular disease; patients are less toxic subacute bacterial endocarditis usually occurs in patients with congenital or acquired valvular disease; patients are less toxic ABE ABE acute bacterial endocariditis usually affects normal heart valves and has a greatly accelerated pace of development; patients are extremely toxic with metastatic infections.acute bacterial endocariditis usually affects normal heart valves and has a greatly accelerated pace of development; patients are extremely toxic with metastatic infections.

Infective Endocarditis Infective agents (most common): Infective agents (most common): - ABE: staphylococcus aureus - ABE: staphylococcus aureus - SBE: streptcoccus viridans - SBE: streptcoccus viridans Risk factors: Risk factors: - Valvular disease, congenital heart defects, rheumatic heart disease, prosthetic heart valves, IV drug abusers, LT vascular access catheters - Valvular disease, congenital heart defects, rheumatic heart disease, prosthetic heart valves, IV drug abusers, LT vascular access catheters

Infective Endocarditis General pathophysiology: General pathophysiology: platelets and fibrin deposit on abnormal endotheliumplatelets and fibrin deposit on abnormal endothelium organisms adhere and colonization beginsorganisms adhere and colonization begins microorganisms or fragments shed into bloodmicroorganisms or fragments shed into blood infarction or infection can occur at any distal siteinfarction or infection can occur at any distal site infection of cardiac tissue can lead to progressive heart failure, conduction disturbances, and dysrhythmias.infection of cardiac tissue can lead to progressive heart failure, conduction disturbances, and dysrhythmias.

Infective Endocarditis SUBJECTIVE DATA Fever: SBE – low grade, ABE – 102 degrees F Fever: SBE – low grade, ABE – 102 degrees F Anorexia, weight loss, night sweats Anorexia, weight loss, night sweats Arthralgia, myalgia, fatigue, malaise Arthralgia, myalgia, fatigue, malaise Dyspnea, cough, pleuritic chest pain, hemoptysis Dyspnea, cough, pleuritic chest pain, hemoptysis HA, signs of stroke, confusion HA, signs of stroke, confusion Abdominal and back pain Abdominal and back pain

Infective Endocarditis Cardiac surgery Cardiac surgery Congenital or aquired heart valve disease Congenital or aquired heart valve disease IV drug use IV drug use Rheumatic heart disease Rheumatic heart disease Cardiac pacemaker Cardiac pacemaker Recent GI or GU disorder with valve disease Recent GI or GU disorder with valve disease Prosthetic valves with recent dental procedures without prophylactic ATX Prosthetic valves with recent dental procedures without prophylactic ATX Subjective Data Suspect if history of:

Infective Endocarditis OBJECTIVE DATA Fever – may be absent in elderly, chronic renal Fever – may be absent in elderly, chronic renal Murmur Murmur “Janeway lesions” - petechial lesions on hands, feet; “Roth’s Spots” on ophthalmic exam; splinter hemorrhages on nails; “Osler’s nodes” – painful lesions of fingertips; petechiae “Janeway lesions” - petechial lesions on hands, feet; “Roth’s Spots” on ophthalmic exam; splinter hemorrhages on nails; “Osler’s nodes” – painful lesions of fingertips; petechiae Splenomegaly, hematuria, proteinuria, clubbing with LT SBE, neurological changes Splenomegaly, hematuria, proteinuria, clubbing with LT SBE, neurological changes

Infective Endocarditis DIAGNOSTICS Blood cultures – most important in decision making process! Blood cultures – most important in decision making process! CBC (anemia common with SBE), BUN/Cr, Electrolytes, Glucose, Sed rate (elevated in both types), UA CBC (anemia common with SBE), BUN/Cr, Electrolytes, Glucose, Sed rate (elevated in both types), UA EKG – conduction abnormalities may be present with septal abscess EKG – conduction abnormalities may be present with septal abscess Echocardiogram – can view vegetation and amount of dysfunction Echocardiogram – can view vegetation and amount of dysfunction Head CT Head CT

Infective Endocarditis INTERVENTIONS ABC/monitoring/reassessments ABC/monitoring/reassessments IV and NS at TKO IV and NS at TKO Labs as ordered – especially MULTIPLE blood cultures! Labs as ordered – especially MULTIPLE blood cultures! Medications: Anti-pyretics, antibiotics Medications: Anti-pyretics, antibiotics Therapeutics – family at bedside, calm, etc. Therapeutics – family at bedside, calm, etc.

Acute Arterial Occlusion Caused by acute disruption of blood flow from an embolism (most common), thrombosis, or trauma. Caused by acute disruption of blood flow from an embolism (most common), thrombosis, or trauma. Majority of emboli lodge in femoral artery. Majority of emboli lodge in femoral artery. Leads to ischemia in areas/tissues supplies by the affected artery Leads to ischemia in areas/tissues supplies by the affected artery Immediate recognition and treatment required to maintain limb or organ viability. Immediate recognition and treatment required to maintain limb or organ viability.

Acute Arterial Occlusion SUBJECTIVE DATA Pain Pain with movement or rest, burning, throbbing, radiates distal to occlusion, excruciating, relentlesswith movement or rest, burning, throbbing, radiates distal to occlusion, excruciating, relentless Coldness, numbness Coldness, numbness Paralysis Paralysis Past Medical HX: Past Medical HX: MI, Rheumatic heart disease, a-fib, cardiac surgery, LV aneurysm, chronic CHF, extremity trauma, recent placement of intra-atrial catheters.MI, Rheumatic heart disease, a-fib, cardiac surgery, LV aneurysm, chronic CHF, extremity trauma, recent placement of intra-atrial catheters.

Acute Arterial Occlusion OBJECTIVE DATA Pallor, cyanosis, mottled, coldness Pallor, cyanosis, mottled, coldness Pulseless (distally), paresthesia, paralysis Pulseless (distally), paresthesia, paralysis Tenderness on palpation, muscle rigor with prolonged ischemia Tenderness on palpation, muscle rigor with prolonged ischemia Petechiae Petechiae

Acute Arterial Occlusion DIAGNOSTICS PT, PTT, CBC PT, PTT, CBC EKG EKG

Acute Arterial Occlusion INTERVENTIONS Elevate HOB (allow for increased flow to ischemic extremity Elevate HOB (allow for increased flow to ischemic extremity Anticoagulants as ordered Anticoagulants as ordered

Acute Arterial Occlusion INTERVENTIONS cont Monitor and reassess (especially the 5 Ps) Monitor and reassess (especially the 5 Ps) Position of comfort Position of comfort Warm environment (DO NOT apply heat to area!) Warm environment (DO NOT apply heat to area!) Maintain extremity at level position (DO NOT elevate) Maintain extremity at level position (DO NOT elevate) Explain procedures and allow family as able Explain procedures and allow family as able

Venous Thrombosis An occlusion of a vein by a blood clot, commonly of the lower extremities, often involves inflammation. An occlusion of a vein by a blood clot, commonly of the lower extremities, often involves inflammation. Etiology – “Virchow’s Triad” Etiology – “Virchow’s Triad” - integrity of veins, stasis of blood flow, & hypercoagulability states - integrity of veins, stasis of blood flow, & hypercoagulability states Factors: age > 40, cardiac disease, malignancy, hx of hypercoag., and use of estrogens and BCPs Factors: age > 40, cardiac disease, malignancy, hx of hypercoag., and use of estrogens and BCPs

Venous Thrombosis The major complication associated with venous thrombosis is ? emboli.

Venous Thrombosis SUBJECTIVE DATA Pain – aching, localized at point of occlusion, constant, worse with walking Pain – aching, localized at point of occlusion, constant, worse with walking Swelling, deep muscle tenderness, fever Swelling, deep muscle tenderness, fever Medical Hx Medical Hx Recent surgery or anesthesia, recent traumatic event, postpartum, prolonged bedrest, heart failure, malignancy, obesity, BCPs, recent MI, thrombotic disease, hematological disorders Recent surgery or anesthesia, recent traumatic event, postpartum, prolonged bedrest, heart failure, malignancy, obesity, BCPs, recent MI, thrombotic disease, hematological disorders

Venous Thrombosis OBJECTIVE DATA Erythema, swelling, indurations, warmth Erythema, swelling, indurations, warmth Deep muscle tenderness Deep muscle tenderness Asymmetry between extremities Asymmetry between extremities Fever Fever Positive Homan’s sign Positive Homan’s sign

Venous Thrombosis DIAGNOSTICS CBC, Sed rate, PT/PTT CBC, Sed rate, PT/PTT Doppler US flow study Doppler US flow study

Venous Thrombosis INTERVENTIONS Position of comfort, elevate effected extremity, bed rest Position of comfort, elevate effected extremity, bed rest Analgesia, anticoagulants, and thrombolytics as ordered Analgesia, anticoagulants, and thrombolytics as ordered Warm, moist compresses to area Warm, moist compresses to area Elastic stockings or ACE wraps as ordered Elastic stockings or ACE wraps as ordered I&O, reassessments I&O, reassessments

PVD Major cause is arteriosclerosis, or hardening of the large and medium-sized arteries. Major cause is arteriosclerosis, or hardening of the large and medium-sized arteries. Symptoms related to the decrease in blood flow to the specific areas; Worsen as disease worsens. Symptoms related to the decrease in blood flow to the specific areas; Worsen as disease worsens. Factors: Heredity, male sex, increasing age, cigarette smoking, HTN, & hyperlipidemia. Factors: Heredity, male sex, increasing age, cigarette smoking, HTN, & hyperlipidemia. Other types: Raynaud’s Disease & Buerger’s Disease Other types: Raynaud’s Disease & Buerger’s Disease

PVD RAYNAUD’S Episodic intense vasospasms of the digits in response to cold or stress. Episodic intense vasospasms of the digits in response to cold or stress. Affects women more than men. Affects women more than men. Vasospasm produces ischemia, which produces pallor followed by cyanosis, coldness, and numbness of the affected digit. Vasospasm produces ischemia, which produces pallor followed by cyanosis, coldness, and numbness of the affected digit. As spasm resolves, there is an intense rubor and throbbing pain prior to digit returning to normal. As spasm resolves, there is an intense rubor and throbbing pain prior to digit returning to normal.

PVD BUERGER’S DISEASE Inflammatory disorder characterized by thrombous formation in usually medium sized arteries of the lower leg and foot. Inflammatory disorder characterized by thrombous formation in usually medium sized arteries of the lower leg and foot. Men affected more than women. Men affected more than women. Results in ischemia, pain, intermittent claudication, decreased or absent pulses, and changes in skin color. Results in ischemia, pain, intermittent claudication, decreased or absent pulses, and changes in skin color. Skin becomes thin and shiny, hair growth retarded, nails thicken, and gangrene/ulcerations may develop. Skin becomes thin and shiny, hair growth retarded, nails thicken, and gangrene/ulcerations may develop.

PVD SUBJECTIVE DATA Pain – cold environment, stress, exercise, relieved by removal of agonist, severe, throbbing Pain – cold environment, stress, exercise, relieved by removal of agonist, severe, throbbing Numbness, tingling Numbness, tingling OBJECTIVE DATA Cold to touch, decreased/absent pulses, pallor, cyanosis, rubor Cold to touch, decreased/absent pulses, pallor, cyanosis, rubor Thin, shiny skin; thickened nails; ulcerations/ necrosis Thin, shiny skin; thickened nails; ulcerations/ necrosis

PVD DIAGNOSTICS CBC CBC Doppler studies Doppler studies

PVD INTERVENTIONS Stop precipitating factors Stop precipitating factors Vasodilators (calcium channel blockers or adrenergic blockers) and analgesics as ordered Vasodilators (calcium channel blockers or adrenergic blockers) and analgesics as ordered Reassess 5 P’s Reassess 5 P’s Position of comfort, DO NOT elevate affected extremity Position of comfort, DO NOT elevate affected extremity Warm environment Warm environment General therapeutics General therapeutics

Myocardial Contusion Usually a result of blunt trauma Usually a result of blunt trauma Injuries may range from petechiae to full- thickness contusions to rupture of the heart Injuries may range from petechiae to full- thickness contusions to rupture of the heart Lesions caused are similar to that of acute MI from occlusions; major difference is amount of hemorrhage! Lesions caused are similar to that of acute MI from occlusions; major difference is amount of hemorrhage! RARELY FATAL! RARELY FATAL! At risk for sudden dysrhythmias At risk for sudden dysrhythmias

Myocardial Contusion SUBJECTIVE DATA Recent blunt trauma to chest, chest pain similar to MI but does not respond to vasodilatory drugs Recent blunt trauma to chest, chest pain similar to MI but does not respond to vasodilatory drugs Pain with inspiration usually secondary to fractured sternum Pain with inspiration usually secondary to fractured sternum Medical HX – angina, previous MI, HTN, CHF, ETOH or drug use, previous CV surgery Medical HX – angina, previous MI, HTN, CHF, ETOH or drug use, previous CV surgery

Myocardial Contusion OBJECTIVE DATA Exam may be normal without signs of trauma or may be associated with severe trauma Exam may be normal without signs of trauma or may be associated with severe trauma Contusion to chest wall, tachycardia, tachypnea, hypo- or hypertension Contusion to chest wall, tachycardia, tachypnea, hypo- or hypertension Signs of LV failure Signs of LV failure crackles crackles

Myocardial Contusion DIAGNOSTICS EKG: Premature atrial or ventricular contractions, A-Fib, SA block, nodal rhythm, AV block, nonspecific ST & T wave abnormalities, BBB (usually right), and infarct pattern. EKG: Premature atrial or ventricular contractions, A-Fib, SA block, nodal rhythm, AV block, nonspecific ST & T wave abnormalities, BBB (usually right), and infarct pattern. Cardiac serum markers Cardiac serum markers Echocardiography Echocardiography CXR CXR

Myocardial Contusion INTERVENTIONS ABC ABC Supplemental O2, monitoring Supplemental O2, monitoring Large bore IV (minimum of 2) & IVF as needed Large bore IV (minimum of 2) & IVF as needed Medicate with antidysrhymics and analgesics as ordered/needed Medicate with antidysrhymics and analgesics as ordered/needed Position of comfort Position of comfort General therapeutics General therapeutics

Cardiac Tamponade Fluid accumulation in the pericardial sac, which elevates intracardiac pressure, progressive decrease in diastolic pressure, and ultimately decrease in stroke volume and cardiac output. Prognosis dependent on etiology & timelines of intervention. Fluid accumulation in the pericardial sac, which elevates intracardiac pressure, progressive decrease in diastolic pressure, and ultimately decrease in stroke volume and cardiac output. Prognosis dependent on etiology & timelines of intervention.

Cardiac Tamponade Causes: Causes: - malignancies, pericarditis, uremia, & trauma - malignancies, pericarditis, uremia, & trauma Types: Types: - acute: patient is in extremis; may be less than 100c - acute: patient is in extremis; may be less than 100c - chronic: patient not in extremis; may be 1-2L - chronic: patient not in extremis; may be 1-2L

Cardiac Tamponade

SUBJECTIVE DATA Penetrating or blunt injury, recent repair of cardiac lesions Penetrating or blunt injury, recent repair of cardiac lesions Dyspnea, anxious, chest pain, fatigue, malaise Dyspnea, anxious, chest pain, fatigue, malaise Medical Hx: Medical Hx: Cardiac disease, infectious or neoplastic disease, renal failure Cardiac disease, infectious or neoplastic disease, renal failure

Cardiac Tamponade SUBJECTIVE DATA cont. Cold, moist skin; cyanotic lips and digits Cold, moist skin; cyanotic lips and digits Decreased UO Decreased UO Decreased LOC, coma Decreased LOC, coma Hepatomegaly Hepatomegaly

Pericardial Tamponade OBJECTIVE DATA Visual wound Visual wound Tachypnea, rales, Kussmal’s sign (rise in venous pressure with inspiration) Tachypnea, rales, Kussmal’s sign (rise in venous pressure with inspiration) JVD,tachycardia JVD,tachycardia

Pericardial Tamponade OBJECTIVE DATA Beck’s Triad: Beck’s Triad: Venous pressure elevationVenous pressure elevation Arterial pressure declineArterial pressure decline Muffled heart tonesMuffled heart tones

Cardiac Tamponade DIAGNOSTICS CXR CXR Pericardiocentesis (Hct will be lower in pericardial blood than venous sample & generally pericardial blood will not clot) Pericardiocentesis (Hct will be lower in pericardial blood than venous sample & generally pericardial blood will not clot) Echocardiogram Echocardiogram T&C, CBC T&C, CBC EKG EKG

Cardiac Tamponade ANALYSIS Cardiac output decreased related to impaired cardiac filling and contractility and decreased venous return secondary to increased intrathoracic pressure Cardiac output decreased related to impaired cardiac filling and contractility and decreased venous return secondary to increased intrathoracic pressure

Cardiac Tamponade INTERVENTIONS ABC ABC Large bore IVs (minimum of 2), IVF as needed Large bore IVs (minimum of 2), IVF as needed Monitoring, reassessment Monitoring, reassessment Prepare: pericardiocentesis, thoracotomy, internal cardiac massage Prepare: pericardiocentesis, thoracotomy, internal cardiac massage Foley & NG Foley & NG Prepare for immediate surgical intervention Prepare for immediate surgical intervention

Traumatic Aortic Injury Result from blunt or penetrating trauma - MVCs are the most common cause Result from blunt or penetrating trauma - MVCs are the most common cause 90% result in complete rupture and sudden death at “the scene” 90% result in complete rupture and sudden death at “the scene” Tearing may occur at points of attachment or may be pinched between the spinal column and manubrium. Tearing may occur at points of attachment or may be pinched between the spinal column and manubrium. Tears not involving the adventital layer (outer) may result in patient survival. Tears not involving the adventital layer (outer) may result in patient survival.

Traumatic Aortic Injury

SUBJECTIVE DATA Deceleration mechansim, blunt force to chest or abdomen Deceleration mechansim, blunt force to chest or abdomen Pain: severe, unrelenting pain in chest, midscapular, or back region Pain: severe, unrelenting pain in chest, midscapular, or back region Medical Hx: atherosclerotic heart disease, prior thoracic injuries or surgeries Medical Hx: atherosclerotic heart disease, prior thoracic injuries or surgeries

Traumatic Aortic Injury OBJECTIVE DATA Dyspnea, tachypnea Dyspnea, tachypnea Tachycardia, discrepancy between BPs in right and left arms, harsh systolic murmur, varying degrees of shock, decreased quality of femoral vs radial pulses Tachycardia, discrepancy between BPs in right and left arms, harsh systolic murmur, varying degrees of shock, decreased quality of femoral vs radial pulses Chest wall ecchymosis, paraplegia Chest wall ecchymosis, paraplegia

Traumatic Aortic Injury DIAGNOSTICS CXR: widened mediastinum, obliteration of aortic knob, tracheal deviation to the right, presence of pleural cap, fx of 1st & 2nd ribs, depression of left main stem bronchus, deviation of esophagus to right, shift of right main stem bronchus up and to right CXR: widened mediastinum, obliteration of aortic knob, tracheal deviation to the right, presence of pleural cap, fx of 1st & 2nd ribs, depression of left main stem bronchus, deviation of esophagus to right, shift of right main stem bronchus up and to right

Traumatic Aortic Injury DIAGNOSTICS cont CT scan CT scan EKG EKG T&C T&C CBC CBC

Traumatic Aortic Injury INTERVENTIONS ABC, monitoring, reassessment ABC, monitoring, reassessment Large bore IVs (minimum of 2), IVF as needed Large bore IVs (minimum of 2), IVF as needed Prepare for blood transfusion & autotransfusion as needed Prepare for blood transfusion & autotransfusion as needed Foley & NG Foley & NG Monitor arterial pH Monitor arterial pH Prepare for immediate surgical intervention Prepare for immediate surgical intervention Administer antihypertensives & beta blockers as ordered if surgical repair delayed Administer antihypertensives & beta blockers as ordered if surgical repair delayed

Arterial Trauma Result from blunt (MVC & crush injuries) or penetrating (GSW & stab wounds) trauma Result from blunt (MVC & crush injuries) or penetrating (GSW & stab wounds) trauma Vessels injuries include lacerations, hematomas, and pseudoaneurysms Vessels injuries include lacerations, hematomas, and pseudoaneurysms Neurological signs usual present due to close proximity of nerves Neurological signs usual present due to close proximity of nerves Major consequence is ischemia distal to injury; immediate surgery required is damage is severe Major consequence is ischemia distal to injury; immediate surgery required is damage is severe

Arterial Trauma SUBJECTIVE DATA Numbness, tingling, pain, paralysis Numbness, tingling, pain, paralysis Mechanism Mechanism Medical Hx: diabetes, PVD Medical Hx: diabetes, PVD

Arterial Trauma OBJECTIVE DATA Hemorrhage from wound, varying stages of shock related to volume of blood loss, pulsatile or expanding hematoma Hemorrhage from wound, varying stages of shock related to volume of blood loss, pulsatile or expanding hematoma Difference in BPs in different extremities, prolonged cap refill, diminished or absent distal pulses Difference in BPs in different extremities, prolonged cap refill, diminished or absent distal pulses Pallor, paresthesia, coolness, paralysis Pallor, paresthesia, coolness, paralysis

Arterial Trauma DIAGNOSTIC Doppler study Doppler study

Questions?????