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Great. I think we're live now. Hello, everyone. Thank you for joining us this evening and welcome to our final session actually, of our on call series. Um Tonight, we've got Chris Waters who is a, was a call trainee and at South me who will be talking through some vascular emergencies on call, which will be really useful for all of you doing vascular job and even in some hospitals where you might cross cover vascular patients and without very much exposure to that, I think that might be really useful. Um Bit of housekeeping start, I think most of you have been here before. But um if you've not used me all before, there's a chat function in the top right hand side of your screens, um Please just write any questions in there as we go along, one of us will keep an eye on it the whole time. So we'll try and answer your questions as we go along. Um, participation has been really good the last few sessions. So if you just keep that up in the chat function, it makes the session really good for everyone. Um And yeah, if there's any comments like this pace is too fast or you'd like us to repeat something again, just pop it in the chat and we'll, we'll try and accommodate for that. Um, I will send a feedback bank at the end, which would be great if you could fill out and we'll take it from there. Hello, over to Chris. Thanks for helping out tonight fab evening everyone. Um, I hope everyone can hear me. All right, if you can't just let us know in the chat and we'll figure something out. Um, like, um, Bora said, I'm a basic core trainee. I'm just about to start reg training and I'm just gonna do a little presentation on vascular emergencies tonight. Um, plan is I've got some cases that I've kind of written up, they relatively brief and the idea is that I will start presenting and I would like it if people can sort of chip in with suggestions as to what they think might be going on or where we might go from here or what kind of thoughts are running through people's heads, we'll go on to a little bit of a talk about POSTOP complications and then at the end, if anyone, I know most of you probably just started surgical jobs, but you've probably all seen a few complications already. If you wanted to talk about a case or put it in the chat at the end, that'd be really helpful and we can kind of use that as an illustrated example. Um And we'll see how we go sick first off. Uh You get one point for this one if you can manage to tell me the diagnosis for a 65 year old man collapsing at home with preceding abdominal pain, who is tachycardic hypotensive. And you're in uh lecture about vascular emergencies, any ideas what might be going on? Lovely, lovely Joly. So let's think of this from the perspective of you being um the F two in A&E overnight. Um And the way I like to think about most cases are you've got some decisions to be made. First decision for any doctrine in A&E is, does this person need admission? Pretty obvious? This person needs admission. So that's fine. Um Next off, when you've made that decision, you, they know where we know they're coming in, where do they need to be cared for? So, while they're in the department, this person is probably going to be in recess and you need to communicate that with your nursing colleagues and just think of it sort of holistically and, and make sure that everyone is looking after people in the right places, then you also think about where they're gonna go after that. So it's kind of two options for AAA they go to theater and have an er, and have it repaired or they're palliated, that's pretty much it once it's ruptured. Um And so that kind of discussion is going to be really important and thinking about that decision frames how you're going to approach things. Um So obviously you're going to follow an I A two, we approach anyone think about um what sort of initial management strategies you might have, what sort of your first few treatments might be thinking you've got this sort of suspicion in the back of your mind, perhaps if we just sort of talk through the first, the aims of treatment. So first off when you're doing your A two E, you're wanting to try and stabilize the patient, make sure they're not gonna bleed too much and die before they transfer successfully up to theater. So for that, it's gonna be a standard A to stuff. And I imagine that most of you are thinking we probably need to give this person some fluids. You're right, probably do. Um There's quite a lot of controversy around the idea of permissive hypotension. But basically the idea being that you don't want to push their BP up too high because you blow off the clot. Um and they bleed more. The first clot you make is the best clot. So if we can manage that, that's ok. The fact that this person has survived to get to hospital usually tends to mean that they have a retroperitoneal bleed by that. I mean, your aorta is com is held held behind your retroperitoneum, which is a tough fibrous structure. And so that effectively tamper out a lot of the blood loss. So that's a good thing in our going in our favor. But still there might be some clot that's minimizing it and you don't want to disturb it. Um, in reality you need to get this person something far more important than fluids. Can you even think of what I'm thinking of? Sorry. It's a horrible question and how you might get it quickly in A&E cross match. Yeah, that's gonna be really helpful. So you're right blood. This person needs blood, they're losing blood, they need to have blood and there's no real substitute for that. And the best thing we're going to be able to do for this person is get some blood into them in A&E you've got an option most A nes, in fact, all A&E S will have a fridge with a couple of units of O negative and that you can just give to anyone. And that's for exactly these situations, an emergency bleeding patient who's hemodynamically unstable. So that's a good place to start any ideas how we might get blood to someone a bit quicker than just sending off a cross match to the lab. And this should apply across all hospitals in the UK, particularly obviously Severn and Peninsula included in that. So, yeah, O negative is useful and that's in A&E the other thing to think about is a um major hemorrhage call. So if anyone's not come across that, that's essentially where you dial in 222, triple two, quadruple two rather. Um and a bit like putting out a um a um medical emergency call, you put out a major hemorrhage call and what that will get you varies in different hospitals, but in general, you'll get basically a lot of red cells and a lot of plasma and that's exactly what you want. Um Why do you want the plasma? Has anyone got any ideas as to why plasma is helpful in a patient who's bleeding? So if you dredge up your memories from first year and you remember the physiologist talking about oncotic and nice idea to think about clotting. Yep. So plasma will have some clotting factors in it. Um platelets sadly don't come in plasma, it's actually spun out and you get a pool of platelets separately. So you get red cells, platelets and um plasma separate different um parts of the blood that you can give people. So yes, it will contain some clotting factors in it, which is great. It's not as much as something say like cryoprecipitate where we literally precipitate out as much clotting factors as we can in a major he call you usually get three shock packs. The first shot pack comes with four red cells, 44 units of red cells, four units of plate, four units of um uh what's the word plasma? Sorry. And um that's it. And that's a good starting point. The second group and the second um shock pack tends to come with the same plus a unit of platelets. And then the fourth shot pack comes with platelets and cryoprecipitate. And essentially you just want to replace it like for like, so you want to give them as much blood as possible. Ideally, we'd be giving them whole blood, but we can't store whole blood effectively. So we have to give them these separate different things. Now, plasma is really useful because of its ability to exert an narcotic pressure. You probably learned at medical school about um fluids and certain starches and such like that Glaus and and whatnot had bad anaphylactic reactions. And how we all prefer crystalloids rather than colloids. Plasma is actually a relatively good colloid because it's got nice large big proteins in it that can't get out of your bloodstream. So they sit in your bloodstream, they sit in your vascular space and they keep that water in there by exerting that oncotic pressure. So in terms of volume expansion plasma is really useful. Um obviously, the red cells are useful for passing the um oxygen around your body and then they contain some clotting factors to try and optimize the clotting. So that's all really helpful and that's all gonna be really useful. Um I would suggest that everyone goes and familiarize themselves with the major hemorrhage called in your local hospital. That'll all be a bit different. They will give you different things. Most of them come with a porter who can help fetch you other things, but sometimes they don't like in bath. I know that they, they didn't. Um And so that's the mainstay of treatment is gonna be aiming to keep your heart rate down and your BP up and roughly, with the idea of not going too high, you want to aim your BP around 100 systolic roughly. And there are various targets for mean arterial pressure that people use as well. Um, some people use tranexamic acid to try and optimize the clotting. To be honest, in my experience, when they're bleeding this much, it's not gonna have that much of effect, of effect effect, but it's not, not gonna do much harm. Um, can anyone think of what other sort of investigations we might need to sort out because the next decision we need to make is where is this person going? Are they going to the ward or are they going to theater? Inevitably they're gonna go into theater. But we need to get a bit more information that will allow us to plan how we're going to treat their ruptured aneurysm. And how might we go about getting that information? What investigations would you guys like fast? Yeah, that's gonna be a particularly helpful investigation in terms of cinching a diagnosis that will be able to identify a AAA. Um, it won't necessarily be able to tell you if it's ruptured. Um, but it certainly points in the right direction. And it gives you an idea of what else is going on so fast. A scans can also look at free fluid in the abdomen thinking about differentials here. If there's been a puff or something like that, any other sort of diagnostic investigations that people could think of and a fast scan is particularly useful because obviously they don't have to leave the department so they can stay in recess, be observed. Have an ultrasound scan if they go off while they're having that, we can sort that out then and there, it's another radiological investigation. They have to go somewhere for, that's not quite as safe, but it is very useful in terms of getting us information. Yeah, CT that's going to be the key factor here. So from a surgical perspective, the thing we need to know is can we fix this with an endovascular repair and that's going to give us the optimum outcome. That's what most centers do nowadays. Very rarely do we do an open AAA repair as an emergency, but it does happen. Um I've just come from South Me where they have a big interventional suite and they have easy access to CT Angio in other hospitals that may not be the case. Um But our preference there, there was certainly to have an endovascular repair. And in order to plan that we need to get AC T A and we need to see what the vasculature looks like, is it technically feasible for us to wiggle our wires around and place a stent in such a way that it will actually sit in the body and not cause more problemss than good. Um Now you always get a bit of kickback from radiologists and radiographers about what's their EGFR, this is a lifesaving emergency. It doesn't really matter because if their EGFR is off and you give them an A K I, they may well die anyway. They're gonna have a, a ruptured AAA. So 50% of these patients will die before ever reaching hospital. Another 50% don't leave hospital. Um They are very high morbidity and mortality. Um So yeah, CT angiogram, that's the kind of key diagnostic investigation after that. There's a few other sort of investigations that we should do just in terms of differentials for abdominal pain and shock, simple things like uh lipase troponin. Um All those kind of things will be very useful. Um But I'm sure I didn't need to get that. Go over that with you when you're taking your history from this chap or the family thereof, any sort of key features you might want to identify that might change some of the decisions you've got coming up bearing in mind that the decisions are operation versus palliation. Um and how quickly it needs to happen. What's gonna be really important from your history to make you determine those if you want, just spits some idea in the chat online. That'd be great. Yeah. So when the symptoms started, so it's good to get a little handle on that. Um, kind of gives you an eyeball of how far gone this person is, how far behind we are on the resuscitation. Good thinking specifically about the idea of whether or not you're gonna go for an operation or if you're gonna go for palliation, any, anything that might, you might have seen your seniors doing previously or thinking about that comorbidities is essential. Vascular patients are sick. They're universally comorbid. They often have DNA CPR S. Um there's a lot else going on. So while past medical history is vital, I think probably the, the most important thing here is going to be the social history. You want to know about the exercise tolerance. How far can this person walk? Will they actually be able to handle a general anesthetic? Let alone a major repair? Um What sort of support do they need? Trying to score them on the Rockwood? Frailty score is a really good way of understanding one, how bad they are and two, it gives you a communication tool to think about when you're discussing with the family. So your, your dad or your mum are very frail. Got a lot going on here. This is something that they may not survive and it, it helps formulate that conversation a bit if there's something pressure on adjacent structure. Yeah, you could certainly think about that and we certainly think about it and in some, in a AAA that's not ruptured. So, if someone presents to us with back pain commonly, and they've got an ultrasound or a CT that showed an aneurysm that was maybe three centimeters, two years ago. And now they're coming in with back pain. We may get another scan and we may see that they've got a sort of five centimeter aneurysm. So, yeah, timeline is always gonna be handy. Uh, risk factor is obviously fairly standard and most vascular patients will have lots of risk factors, smoking hypertension, those being the big two. But diabetes as well. Does anyone know of any infections that cause mycotic aneurysms or infective aneurysms, particularly of the aorta? Just for bonus points? The one that all the textbooks quote is syphilis. So always worth thinking about um particularly in younger patients. Sorry, the question was any, can anyone think of any particular infections that cause um, mycotic aneurysms? And the answer I was looking for was syphilis. Um, there are a whole host of different infections that can cause it, but that's the sort of textbook answer. Um, particularly important in uh both IVD use and um in younger patients with large aneurysms. Um That's kind of all I have to say about triple A's, to be honest, as F ones and F two S, you're probably not going to be getting involved in those kind of cases. You might be asked to go and do a quick larking on someone while they're being wheeled up to theater. Um, but it would certainly be a good opportunity for you guys to learn about, um, resuscitation and intensive care within a, um, uh, a sick surgical patient. Um, so the other thing to think about is there is about transfer and stuff that's more of an anesthetic sort of discussion. So that's just one to sort of get an idea of what's going on. So next case I've got to think about is another one that will sort of come in on your take and let's say that you are the F one and in South from where I worked, what would happen is the registrar would get the phone call about what's going on and they would say bring the patient into sau um from the GP. And then the F one's job was to clerk, sort them out and then the registrar will come and review them. So you've got a 56 year old chap. He's on the waiting list for an endovascular aortic aneurysm repair. And he suddenly exc experiences excruciating pain in his left calf and foot and it's preceded by some pins and needles. He tells you he's got slank tachycardia and he's a bit hypertensive, he's a bit tachy, but otherwise, observations aren't drastically shocking. Has anyone got any ideas of what we might think might be going on any differentials at this stage or don't you lack any more information, acute limb ischemia, another vascular classic. So, yes, well done. Um And the idea here being that this person has either embolized from their existing um AAA. Um and a AAA obviously, because it's a large swelling, it's got turbulent flow, it encourages thrombus formation. You commonly get thromb mural, thrombus, build you up on the wall that can either break off, travel down and go into one of your more distal arteries. Um and give you a classic kind of pain in a particular arterial distribution. So, calf and foot, that's gonna be your posterior tribual artery probably. Um And uh nice six p are what we need to look out for there in our history and examination. Um So let's think about decisions again, decisions, this person coming in. So admission, yes, that's all sorted. Next question. Is it salvageable? Does anyone know what w what would determine whether a limb is salvageable? Any factors we might consider? Sure collateral supply? Yeah, that's going to be important in the pathophysiology of how this person survives. When it's a sudden event like this, they're not going to have had time to develop collaterals. So, collateralization happens when you chronically, you're chronically ischemic in your legs. Um The way I like to explain it to patients is I talk about motorways. And so I say that as your main motorways are flaring up and they're closing down the lanes, your A ross and your bros start to open up a bit and that only works if it's slowly getting worse and worse. And that's why gra graduated exercise programs have such good evidence for them for treating chronic ischemia. Um, so that, that's, um, something to think about length of time ischemia has occurred for. Yes, absolutely. So, the classic thing is less than six hours. It's salvageable. Um, and anything longer than that, it's a bit worse. Great idea. thinking about sensation. So, um the six ps, they have an order in which they happen. And first off, you get the paresthesia in the neurological symptom, particularly, you get paraestesia first, that's the pins and needles. They're describing the tingling sensation in their leg, then comes the pain and the pain is typically out of proportion to anything. So they may have said, oh, I bumped my leg, but it's really, really hurting and it, they're screaming in pain. It's 10 out of 10 doesn't quite fit with somebody who's just bumped their leg. Um And after that, they get paralysis and that's where they lose motor function. And so essentially your sensory nerves are the most sensitive to ischemia and your motor motor nerves are least sensitive. So you preserve them for as long as possible. So, yes, preserved sensation of an indication that actually this is a relatively fresh thing and actually, we can probably get in there and we can probably save the limb. So you're absolutely right. That preserved sensation would be a really positive um indicator. Often by the time they actually get to a vascular center, they've presented to another A&E they may have sat on it for an hour or so at home before coming in, wait another two hours for an ambulance. You know, it drags on by the time they get to see you, you're often at the pain stage and then you, the crucial part of your examination is assessing their motor function. It's actually assessing their power. It's a really useful way of gauging if this leg is salvageable or unsalvageable. And the other thing to think about is the appearance. So typically you'll get increased uh erythema across the whole leg initially, then it will go pale and then it'll go muffled and mottled. It has a very distinctive characteristic. It's what happens when you get really cold. Uh And you can, you start to shut down a bit, you get a bit pale and you have these kind of circular uh patches that are slightly more purple. Um And that often doesn't change when you press on it. So often you're checking for cap refill in these patients. And with modeling, there will be no cap refill. With Pala, there might be some cap refill. Um And then with erythema, there will still be cap refill, but it just might be a bit extended. Um So just thinking about pain out of proportion, let's think about this a different way. So this patient has say just had an a and they now sat on the wards and you think that it's most likely that they've thrown off the clot during the operation. How would you establish that this is pain out of proportion? What analgesic would you go in with that? You would expect most pain to settle with? What be your go to analgesic? Let's forget about the who pain ladder. Say someone's in excruciating pain. What are you gonna give them in order to allow you to reassess them later on and see if that pain has gotten any better. Morphine. Yeah. So Oramorph if they can take it IV morphine, if you can give it most wards you're not allowed to give IV morphine on. Um So it's often Oramorph and most or um if their renal function can take it and a good standard sort of big dose um is about 20 mg. Um, peine good thought again, depending on renal function, et cetera. Um But yes, morphine is kind of the standard thing of you get the phone call from the nurse saying what's happening, you give them a big slug of opiates. You go and see them have the opiates helped. The opiates haven't helped. That's pretty classic for um pain out of proportion. Does anyone know about the initial treatment here? Um Once you've done your usual A two E what's gonna be the sort of how you tide someone over? So that we can get them to definitive management. Medical therapy is gonna be important. Exercise is gonna be important and that will depend on the functional status of the patient. If they're very comorbid, that will be the case. However, that would, that, that's also high risk. Um And anticoagulation is gonna be key. The thing we tend to do acutely is we tend to give them an infusion of unfractionated heparin. Um And that way we prevent the clot from propagating. We prevent, we try and preserve their blood flow. Um With the view that long term, we can switch them to an oral anticoagulant. But in the initial time, that's what we do. That allows us a bit of time to get some more information and information again, in vascular. Our favorite investigation is gonna be the CT angiogram. We want to know where that blockage is and what's caused it that allows us to make a treatment plan, treatment plan for revascularize, revascularization. Sorry, long word. Um You've got a few options. It depends where the clot is given. This is in a left calf. We're probably thinking this is in a posterior tibial. So in that case, you're probably looking at two options, you can either do a bypass or you take a bit of someone's vein and you bypass the bit that's blocked or if it's a nice fresh clot like that, you may be able to fish out with an Embolectomy and that can be done either endovascular or open where you make a cut down and you fish out the clot. Yeah. So balloon, um, balloon angioplasty can be helpful in terms of widening things. Um, stent is good in the, um, pelvis stents below that are tricky because stents in legs get bent. And if you imagine, um, a tube like say this pen, it doesn't bend, it just breaks. And what happens to a stent is it kinks and it kinks and it clots off. Um And so that, that kind of tube that was nice and straight when it gets under a lot of movements or in your groin or something like that, if it moves too much, it's, it clots and occludes. Um, so we don't tend to do the stents in the legs, but we do it in the IAC balloon. We can do. Um, but Embolectomy and that's either with a catheter, Embolectomy where you put a balloon, you thread your wire down, you put a balloon beyond it and you pull it out or you do an open operation where you cut down and you take that clot out. Um Those are kind of two Embolectomy options. Um So as an excellent F one or F two, the best thing that you can do in order to expedite this patient's treatment is gonna be give them some good painkillers, keep them, no, by mouth, get them prescribed some IV fluids just to keep them topped up. Um, alert your seniors ideally get a consent form ready. And uh that by that mean, I don't mean you have to consent them, but if you're surgically inclined or you're interested in thinking about that kind of stuff, um, what you could do is, um, start to prepare the consent form. Um and look at things about, think about what you think might be the risk of this particular treatment you're planning, show it to your boss when they get there and maybe when they're there, you can think about doing a supervised mini ca for taking consent, um book the patient on the theater system and let the anesthetic team know as well as the theater coordinator. That's all these kind of extra steps that are always gonna be really hard when you're stressed out, you're busy on call. If you have the time, it's a really good learning opportunity, sort of figuring out how to get someone up to theater because the practicalities of it is not as easy as er all the bosses make it look, particularly when you're a consultant, you've got the power just to go, they'll do that sick. Um This is something called the Rutherford classification. You probably came across at medical school and it essentially just tells you about whether or not this person is going to end up having palliation or amputation or if they're a, a candidate for re revascularization. Um and it maps out all the things that you you, we talked about um the other thing to think about is other bedside tests. So obviously thinking about dopplers and palpating pulses is going to be absolutely essential here. That way we can gauge for where the clot might be. So say if they have a palpable femoral and popliteal pulse, but absent dorsalis penis and postero tibial, you know that the clot is somewhere between their popliteal and their dorsalis pedis or um probably in their A T trunk if both are recruited. Um Now, uh oh no gruesome pictures of this one. So that's pretty much it for acute limb ischemia. Um Key things are gonna be getting that CT angiogram, um getting a group and save um always helpful if you're gonna think about going to theater and starting some IV heparin and some analgesia. Um That's kind of it. Case three is another one that crops up a lot on. Um take um probably makes up the vast majority of the vascular wards workload. Um A 64 year old lady is referred from the medical take with a swollen red right foot. Um She's got a background of COPD type two diabetes, previous left hallux amputation. Um She's a little bit septic, slightly hypo, uh slightly tachycardic and uh febrile um with slightly low sat on her and slightly tachypneic. Anyone got any worries at this stage. So, life is good thought. Um Certainly an effective process of some variety. Anything in there that makes you more worried. Excellent to think of DVT. Definitely on your differential list when someone is diabetic and they have a hot red swollen foot, that is another vascular emergency diabetic foot sepsis. These patients can get very unwell very quickly. Um, and it's really easy to overlook them because that's just a bit of cellulitis will be fine. Um, these patients can get really sick, they can get, become septic and their infection can spread quite rapidly because of their diabetes. Um So these patients are ones that you need to keep a really close eye on. Um And they need to be managed quite carefully in the hospital. So that takes the decision of admission away. They're definitely coming in. Um Next for them, we need to think about how urgently we need to remove the infection and by removing the infection, I mean, perform an incision and drainage of an abscess or a debridement which sometimes remove in and it involves removing some toes. Now, when you look at a patient like this, there, any factors you might consider they'd need more urgent to bribe and say they came in right now at what is it? 6 30 now. Um And they ended up having, uh seeing the boss. Now, um What sort of things might push them to have an operation overnight rather than staying and waiting till the next morning, who might be more worried about leaving because obviously they all have conservative management with some antibiotics initially anyway, particularly because she's septic. Um, but we do need to bride a lot of these patients kind of the things you would expect if they're frankly septic and they're not settling. So they've had their dose of, say Tazo. That's what we use in M BT. But it'll be any kind of broad spectrum antibiotics most of the places. Um, if they've got a very high CRP. Yeah. So definitely fact that she septic spot on auto, um, CRP generally above 100 often gets an operation that night. Um, the other thing that operations are very good at is getting rid of pus. So if the foot looks like it's got a lot of pus trapped underneath it, it's got some foggy swelling in the foot, that's gonna be really important. So, again, you kind of approach to this is giving them IV antibiotics, painkillers. No, by mouth getting a consent form ready, potentially marking the leg so that they know what's happening, um, and alerting the theater coordinator and the anesthetic team. Um, there are some important investigations to get in this one. Can anyone think of any important investigations here that's gonna be, and that will change how we manage this patient. Foot x-ray. Absolutely spot on that is exactly what will change our management overnight and we'll come on to x-rays and what we're looking for there later on. But the reason we do the x-ray is we want to look for either osteomyelitis or gas gangrene, both of which are indications for urgent debridement. Um Osteomyelitis less so gas gangrene. They need to go tonight in the next couple of hours. Really. Um Blood cultures really important. Anyone as septic. Absolutely essential. And the microbiologist will tell you that every time, um ideally before they've had their antibiotics, but if it, if it's gonna delay their antibiotics, just get it into them. Um So yes, those are two very important things. The other thing is obviously an HB A one C, you need to check it how well controlled their diabetes is. Um And we can think about optimizing their medical management depending on what they're on. And, and maybe with some input from our diabetic specialist nurses who are usually absolute, absolutely wonderful and very helpful. The other thing we think about in a vascular setting is what the perfusion is like. So while they may be diabetic and they've got a diabetic infection, they are also inevitably gonna have a poor blood supply if they're diabetic. And if this person got CPD, that means they are either are a smoker or were a smoker, they've already had an amputation previously. So, assessing that they're perfusion is really important. So we'll know how we assess perfusion in diabetics, some sort of objective test for, for perfusion, not just cap refill dopplers. Yeah. So Doppler are really helpful um particularly in terms of an arterial Doppler mapping it out A BP, you fell for my trap. I'm afraid there. Yes. So, an A BP I, we can do um the disadvantage of A BP in diabetics is that diabetics tend to get something called arteriosclerosis where their arteries, they get a lot of calcium deposits in their arteries, which means they, the arteries themselves become incompressible. So when you put that BP cuff around their ankle, no matter how high you squeeze it, that little pipe that's made of pure rock is not going to get compressed. So an A BP gives you a falsely elevated reading. So what we tend to do is that affects your medium and large blood vessels, it doesn't affect your small blood vessels. So we can do something called toe pressures. Now, they are rather than a ratio, they give you the absolute pressure value um for what it the capillaries is running into your toe is like and generally anything over sort of 60 is tolerable, anything under that, we probably need to do something about that perfusion. Um Don't worry about the numbers not important. Um But it's more about just knowing where we go and how we assess them. Having an objective measure of that is gonna be important, but often that's an investigation that requires a vascular scientist. It's something that has to rate until daylight hours. So it's not gonna change your management overnight, but it will change what we do in the future. So as an F one on call that night, the foot x-ray changes what you do overnight, the toe pressure changes, what you do in the future. Do they need a bypass? Do they need some stenting something to increase their um blood flow down there? And someone else has written about fluorescence angiography again, really good option if there's a lot of provision of it. Um Sadly, in most of the hospitals in the South West there isn't. Um It gives you really detailed pictures and obviously you can intervene at that time. So once we've got our toe pressures, we may consider doing an angiogram and at that time, we may also consider doing an angioplasty to widen things up. Um So yeah, good thinking. Um, the other thing to think about is potentially as well as a uh an arterial duplex. An arterial Doppler is a venous Doppler. And the reason we do a venous Doppler is to map out if there's any decent size veins in their legs. So that if they needed a bypass, we know that we've got a conduit and what we do there is we take the vein out and we plumb it in and we bypass the area that's gone, that's blocked, that's blocked or has lower flow. Um You can do that with plastic, something called Dacron, but that's at higher risk of infection compared to using someone's own vein. So those are a few little added extra investigations that will make you look really slick in front of your ridges if you can remember to request them. Now, yes, if anyone is about to have dinner, which given it's now a quarter to seven. I don't imagine a lot of you are. Um, look away. Now, there are some gruesome pictures coming up. It's because diabetic feet, you need to have a look at them. You need to have a smell of them and we all know they're gross. We all know they're horrible, but it's really important to actually have a look at them. So when they're wrapped up in bandages, take them down, have a look if your hospital has medical photography, try and get them to take a photo of it. So you don't have to take the dressings down when your boss gets there. Um, but say a warning 54321. Brutal picture number one. So this doesn't look so bad. Um I'm just gonna talk you through. I'm sorry, I, I would go just in, in the interest of time, I think. Um, we'll just quickly whi through this, but essentially from here you can see there's a lot of erythema around this foot, um, around the sort of midfoot there. Um, it looks a bit swollen, but generally that's not too bad. I think I would agree with your early diagnosis that that's probably an element of cellulitis. And if this is in a diabetic this, it's probably diabetic cellulitis, I'd like to get an x-ray just to check. Um But I don't necessarily think that this person needs to be rushed to this. I apologize the quality of that image. It's not looking great now that I see it projected up there, essentially, if it's just a bit of erythema, bit of swelling, I'm not overly concerned. Now, that is a whole different story. That is a big bit of tissue loss, that is a big bit of exposed tissue that's gonna need debridement and that's probably gonna need debridement fairly urgently looking at how extensive that is that may well even need an amputation. And we're talking there probably a below knee amputation. Um Most diabetic foot infections start in the toes. So we can often get away with sort of toe amputations rather than below knee amputations, but that is sometimes required. Um And now this is the same foot. All, all three po photos here are the same foot at different times. The first one was at day one. The second one was I think at day 10 and this one was at um I think day six or something. I think now this one you can see the erythema is a lot more extensive. It's a lot more swollen and in that central area, you can see there are some sort of blisters that look like they got pus in them. This is one that we're gonna want to take to theater tonight. And the reason is we want to drain that abscess. We want to get that pus out of there. If you leave pus in a foot with diabetes, the pus takes hold and it just latches on to any bone in there. They get Osteomyelitis and it just goes higher and higher and higher. So, a really good thorough washout is gonna be essential. You need source control. That's what the micro describe it as you need to get rid of as much of the bugs as possible. And then hopefully the antibiotic can do their work. That's also where doing the revascularization helps. So if you improve the blood flow, you improve the delivery of antibiotics to the area. So they don't have to happen simultaneously, but often during the same admission, we'll do a debridement and then we'll do a revascularization. Um So those are some gruesome pictures, really interesting paper in my, in my references, if anyone wants to have a look at it, um It's, it charts the course of one person's diabetic foot infection from day one to day 10 and you can kind of see how it evolves and this patient was very lucky. They managed to keep their foot um through conservative management only. And that little scar there is what they've been left with. Um, which unfortunately, on the vascular ward is not typical of all our patients. Um, but it's worth a read if anyone gets a chance. Now, x-rays um, spot diagnosis here. If anyone like to pop it in the chat. What you can see here, um, uh, comment on whether or not you'd like to take this person to theater tonight or tomorrow. And I wouldn't necessarily say that. I think that the bone health itself looks ok. Cas gangrene. Yeah. Absolutely. Well, on Boris. So, um, you can see in the soft tissues there's lots of areas of lucency and you can see it spreading all the way up to the, the leg. You can see it in the back of the calf and the front of the calf. This is severe infection. This is someone potentially with necrotizing fasciitis. This needs to go to theater for debridement and possibly even a fairly major amputation. Um So that's an example of how an x-ray will change your management. This any thoughts on a diagnosis for this one another spot diagnosis, which parts I'm referring to? Yes, sorry, I can, Boris. Is there a way I can draw on this? I'm assuming not, but essentially you see under the skin. No, never mind. Um under the skin there is you see these little lucent bubbles almost. Um I guess it'd be more helpful if I had a normal x-ray to show you. Sorry. Um The the skin sort of directly behind, directly above the calcaneum is relatively normal, but the little pockets of lucency that you see around it and the fluffiness that's all gas within your soft tissues. Um So you can see, particularly on the anterior surface of the um, ankle joint, there's lots of bubbles under the subcutaneous tissue there. You can see it's, it's tracking all the way up in a sort of layer up into that anterior shin as well. Um You can see it on the sole of the foot and the sort of fluffiness there. Um, lots of nasty bubbles which you wouldn't typically see in an x-ray of anyone else's ankle. If we took an x-ray of your ankle right now, you wouldn't see that. I had to go anyway. So that one, anyone got any ideas as to what the abnormality is here just in the interest of time. Mohamed, we'll come back to it if that's ok. If there's time at the end, anyone got any ideas as to what might be going on here and how this might change your management in the context of a diabetic foot infection. Let's say they have an ulcer over their distal fifth metatarsal. Yeah, osteomyelitis. Absolutely bony destruction. So this is a very clear and obvious um example of Osteomyelitis. Um other things you might see, you can kind of see there's some osteopenia like you talked about earlier, the Demi demineralization. Um So that's the kind of loss of um you can see how, how much less dense that bone looks in comparison to the fourth metatarsal. Um The other thing is to think about periosteal thickening. So you can see just at the edges where that's starting to become AAA lytic lesion in the base of his fifth. You've got the kind of periosteum kind of lifting away like that. And that's periosteal um sort of thickening and reaction. And that's essentially just showing you that there's some inflammation going on in the bone, bony lysis like we've seen there. Um and it's kind of, you just generally lose your, your normal bone architecture. So important changes to look out for. Sadly, an x-ray does not exclude Osteomyelitis and a definitive investigation would be an MRI. So if we are highly suspicious of the ongoing Osteomyelitis, we get an MRI, but that's not something you don't typically get overnight, that'll probably take a few days to get sorted with radiology, say that is that that's kind of diabetic foot sepsis. So, um key things there are get an x-ray, give them some broad spectrum antibiotics, take them seriously, don't just brush them off. Um It's not just cellulitis, it is a more um deadly disease that needs taken seriously. Um and um have in the back of your mind, there's other differentials. We talked about thinking about DVTs, et cetera. That's really good thinking. Um And then doing the simple things and doing, doing them well is kind of key for these guys. Um think about their diabetic management as well, optimizing their medical treatment. We've got one more case, I'm aware we're running out of time, but um we might just try and actually I'll tell you what, we'll skip this one and we'll go on to have a little chat about complications. So this case is I was going to talk about is essentially something called um, chronic limb threatening ischemia. It's often referred from our hot clinic. So we have a clinic that the GPS refer to urgently and they're seen within usually about a week. Um And if they're um ischemia, so if they're known to be arterio pas, and they've got an element of ischemia, if they, they're getting rest pain or they've got tissue loss. So they've got ulcers, they often get referred to this clinic and then our bosses see them and they decide this needs sorting. Now they either need an amputation or a revascularization or both. Um And so this is some photos of um patients with chronic ly threatening ischemia. It's different to the acute limb ischemia in the timeline and in how it appears. So this one, the patient here has got a second toe dry gangrene. And the key difference between dry and wet is that dry is safe to leave. It will just auto amputate or fall off of its own accord without allowing infection to track up. If it's wet, there's evidence of infection there and I will show you a photo of wet next that dry, sorry. So that's not so worrisome, very gruesome apology. That's a mummified foot. Um This is wet. This is um where you see lots of kind of puffs, it looks a bit more boggy, it's just not very pleasant. That's something you get really worried about. Um um And that, that, that needs debriding and probably amputating fairly urgently within the next 24 hours. Whereas the dry stuff can wait. The system we use for assessing um chronic lymph affecting ischemia is called the wifi classification. I won't go into it. But if anyone wants to go and do some reading about it, it's really interesting and essentially it's a way of predicting who's going to go on and require an amputation. Um The key is that we need to balance our assessment of how bad their leg is with what their functional outcomes gonna be if we think about giving them an amputation. Um Now, surgical complications. Um I borrowed this slide from somewhere else because um it took me really a really long time to understand that surgical complications happen at different times. Um You guys are probably a lot smarter than me and figured this out already. But I find it really helpful to think of in terms of any surgery. I think this particular chart refers to mainly abdominal surgery, but still it's pretty common to all of them. Um And the complications that I just wanted to sort of draw your eye to are the, the sort of common things in day one and day two in any operation is basal Atis because of pain. People don't take deep breaths and that tends to happen. Day one day two. That can explain fevers in the first of the 24 48 hours after surgery. Um, after that, you're thinking more along those of chest infection or pe s um, and pe can happen at any time. I would argue that can probably go in 1 to 10, uh, day one to day 10 cardiovascular. Don't forget about people having myocardial infarctions, strokes. A f very common in vascular patients cause they've all got vascular problems, bleeding. I'll talk out in a tick. Um urinary retention again, very common after any operation, particularly abdominal, but any of them acute kidney injury common with lots of vascular operations because we use contrast and we use intraoperative x-rays. Um So it's very common for them to get kid uh A Kas afterwards and sometimes they require renal replacement therapy. Um Gastro intestinal that's mostly around G I stuff. Um and likewise pain. There's always a bit of pain and that's always gonna be a bit of a, a challenge and trouble wound infection that can crop up from day three onwards. Deep infection, probably more. Looking at day 7 to 10 in my, my experience, but everyone finds it different. Um And the key is when, when the nurses are sort of phoning you or you look at someone's CRP and it's jumped up, you need to know what day, POSTOP they are. So it's day one Ok. That's fine. It's just a POSTOP reaction. If you're looking at day four, day five, the CRP has been trending down previously and now it's jumped back up. That's when you get suspicious of wound infections and deeper infections. Um, think about vascular. I've kind of gone along the same vein and tried to make my own little table day one is kind of obviously gonna be the most high risk time after any operation. Um And you're thinking about a few things, the way I split up is arterial venous and endocrine, basically because they weren't mentioned in the last table. Um Endocrine, I'll just quickly go over most of our patients diabetic. A lot of them end up getting DK A or HHS post-operatively because we've messed around with what they're eating, what their insulin regimes are. Um all kinds of things and they're just sick when they get to us throughout their whole admission. They can have hypos and hyper. Um And that's about optimizing their um diabetic uh treatments, venous wise, venous bleeding. Now, venous bleeding is one of those things that's gonna happen slowly. It's not gonna be as dramatic as arterial bleeding and it can happen most commonly day one, probably get a bit on day two and day three when people start to get up, move around and they start to pull some stitches around and move your wound around. That's when you may get a second spike in bleeding. That's venous, um, DVTs and PE S they happen at any time all the time. Um, every surgical firm, uh, no matter what you're on, would much rather you put people on Xan when you weren't sure than didn't, we can deal with bleeding. In theater surgeons are very good at stopping bleeding, but dealing with the clots and all the paperwork with it is not fun. Um, thankfully that doesn't tend to happen now that we have good um BT assessments. Um So please keep filling those in long term wise. You get something called post thrombo thrombotic syndrome. If you have AD VT in it or you can get it. About 50% of people with massive massive DVTs can get it and essentially you're left with a weak painful leg post DVT and it is horrific, really difficult to treat and very nasty. So doing all you can to minimize it is important. Um And while I put that in day 10, that tends to happen for months down the line and there's no way of predicting who's going to go on and get it. Um Unfortunately, now arterial, that's gonna be the thing that kind of concerns us the most cause that's gonna be the most uh dramatic complications. So day one after any operation, particularly thinking about revascularizations and embolectomy and where you're improving the blood supply to something is compartment syndrome. You've suddenly improved blood supply to an an area that didn't have good blood supply before. So you're gonna get a lot of swelling and that swelling can happen within a compartment. And the compartment syndrome signs to watch out for are exactly the same as the acute no ischemia signs. The six pe nice and easy to remember. The only thing to remember about the only extra thing to remember about compartment syndrome is that there is pain on passive um extension of that particular compartment. So if it's in the leg wiggle their ankle around, if you're in agony, you've got compartment syndrome. Um and that tends to happen in the first um day after surgery or in the sort of immediate few hours after surgery. Um Now, because we're fiddling around with arteries, you can get distal embolization. So a clot is thrown off from wherever we're operating on. Um And that can travel down and land in your foot and your leg give you pain in your leg. Again, that tends to happen 1st, 1st day, sometimes day two, day three as people get up and disturb things or miss some medications. Um when we've done a bypass graft failure or stent occlusion is always a risk. Now, its highest risk is day one, but that risk is stays lifelong. The risk drops off as you as it. Um So the risk of embolization drops off as you go down the days, but the risk of thrombosis goes up and thrombosis is that slow flow state rather than the embolization that's sudden thrombosis is a slow increase in thrombus building up and a slow decrease in your supply of blood to the bit beyond that. So, graft failure or stent occlusion can be bad news for a vascular surgeon. Um but all stents will eventually fail most of the time our patients die of something else beforehand. But if a stent fails, you can do s some things about it, but the treatment is not optimal and then bleeding, arterial bleed, big dramatic thing. The only thing you can do is press on it and call for help. Um Venous best thing to do is press on it and probably call for help. Um That's about it. That was kind of everything I wanted to say. I'm sorry, I've run over by one minute, sorry that last bit turned in very didactic. But thank you so much for everyone's participation. Has anyone got any other questions or comments to make about stuff or any questions from any cases you've seen on the wards? And um if anyone's interested, those are the um references mostly for the pictures. But um that new England Journal of Medicine, that's number two is quite an interesting read. And Podiatry today has a good article that talks about um how the wifi um classification is used on how to do it if anyone's interested in some further reading. Um And I was gonna go back to something and the heel. Yes, let's have a look at the heel, shall we? Um, I'm sorry. So the heel itself bit difficult to see in this projection, always ask for two views. Um, there is a little bit of lucency just above the Calcaneum. Um, otherwise it's not too bad, that very dark spot underneath the heel that you're looking at. I think that's an artifact. I'm not, I'm not convinced that's a true problem. Um, is there any other bits you are particularly worried about Mohammed that you uh you wanted to point out, but the, the biggest, the biggest, most dramatic bit that you can see is on the anterior surface of, of the, this is the, the dorsum of their foot. Sorry, that was a whistle whistle stop tour. Um If anyone's got any more questions, feel free to email me or get in touch. Um Likewise, if anyone wants to talk about surgical careers, very happy to talk about that, I've had a very up and down career path. It's not been your typical surgeon. So, um yeah, um just get in touch. Great. Thank you very much Chris. Um For else that you've seen, I put the feedback link in the chat, if you could all answer to that and um on completion, it should also generate a certificate on your med account which you can upload to and it as an hour of co teaching. Um Also if you want to rewatch any of the sessions that should all be available on the med page. Um And yeah, that's the last of our on call series at the moment. We'll be in touch if we, when, as, and when we, we, we launch a new series. So keep an eye on either the med all or the Facebook pages and we'll try and post it in the groups as well as we as we go. But thank you so much, Chris. Thank you guys. Good. One thing I just thought of as I was just rattling through that last section would a sort of session on um, surgical complications be useful just in general, like the POSTOP complications in general. Yeah, I think so. You get to a lot. We had a session on some surgery presentation. I was not sure if it was POSTOP complications and, but yeah, certainly down the line. That would be very useful. Ok. Cheers. I will send you in the feedback and things as well. Much pleasure. Thanks for having me. Thanks a lot. Have a nice evening. Take care guys.