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Okay, So, welcome, everyone. Teo the mind of deep surgical series. And today we're going to talk about vascular surgery. Emergencies on. It's a special event which is sponsored by MG on. We're going to Teo. One person is going to win a raffle price, which is their subscription to our sweet and salt electricity Aires. And so thank you very much mg for the postpone Cering, the session. So, um, the session today, um, we're going to cover it pretty much. We're going to follow the same format as every week. So we're going to talk about, um the clocking on Do your going to pretend you're a trainee in cool. We're going to talk about breathing, Natalie in pathology, on disease and geology on some investigations that you might need. Then, most importantly, we're going to talk about initial management and some complications on we're going to incorporate some interrupt questions for right. It's the key. Learning points are going to be understanding they're relevant in after me off the circulation system, identifying vascular surgery, emergency presentations, understanding the risk factors, or faster surgery emergencies. And we're going to practice application of this knowledge using cases and the questions. So my name is Sarah. I'm an academic. If I too, doctor And I'm interested in plastics and ask the surgery training in research on. But I just want to briefly mention, um, we have a special discount for you were cooperating with COPD me platform on day. If you go to mind, please dot com slash drawing slash COPD me. You can get a 50% discount, and it allows you to track your portfolio and bill your that you're a medical medical teaching experience. So let's just play a short video by the MG and we'll crack on the session. Thank you very much indeed. Um, you can apply using Twitter, Facebook or joining one instagram on. That's correct on the session. So you're on the surgical. Take your Gina on. Do you have a patient coming free, so please keep them. Keep this in mind as we go for this lights. So the first patient stats comes free is his name is John. He's a 75 year old male, and he presents with sudden onset back pain and collapse, and he's sweating clammy. So for the session today, we're going to use mental meta so I'm just going to give you a second to join. All right, so if you use the code at the top, it's triple for 13900. Then you can join me on mental meter, and the first question is what? They're differential diagnosis for somebody with back pain and collapse so you can just have to go tomorow w dot menti. That's m e N T. I don't calm. And he's the code, which is for it for for one free nine double zero. And it's at the top of the screen, perfect to have fast for joining. So just to remind of everyone we have a 75 year old patient who comes in with back pain and collapse and he's sweating, clammy, and I know this is a vascular emergency webinar. So obviously the answer is probably quite obvious. But just think about the differentials. That's not only involve the vascular system perfect, so we have some unserious back over different system. So am I. Or originally at that is highly likely, though present with chest pain, but could sometimes radiate and and can present of the collapse kidney stones. That's a very good differential um, a disc this collapse? Yes. If it's very painful, the patient can present with, ah, with collapsed, they can be in. Well, um, perfect. We're going to use the same codes on mental meter for the rest of the session. But for now, let's go back to our presentation. All right? So the main differential diagnosis and you got majority of them. But the renal colic, That's a very classic, very classic differential because it does present with Mobic alone to growing pain or back pain, which, um, a ruptured aneurysm can present with a swell or Egyptian aortic abdominal aneurysm. And to this very want to bury it. Very important. One to bury in mind that verticulitis inflammatory bowel disease or irritable bowel syndrome hemorrhage in the joy system that will make the patients shocked and well, and it goes back pain and collapse. Pancreatitis. It's my card infection and aortic. There sections. You've got almost out of them so far, then all right. Sit up for to this case, we're going to follow our usual formats. So we're going to take the history in this case might be a little bit difficult because the patient presented with collapse, but for the purpose of the cetera. Going to assume that by the time he arrived he felt better. So we're able to speak to him. We're going to examine the patient in. He's very unwell. We're going to follow that a t e approach ongoing. Teo, think about some investigations Bet side bloods and radiology and the French of diagnosis Become it ready. All right, So for the vascular basket Very, um, a disease for vascular area, um, symptoms and signs. The important thing to ask about it would be confusion on urea, which essentially means that the picture is not producing you written. And that is, in this case because patients kidneys might not be refused because of the aortic aneurysm. I'm stealing. We'll do blood or the aneurysm rupturing. So that's a very bold and sign. And we have to assess for this on basketball. This innovation, he might have expected of them New York aneurysm leg pain, because legs are not getting perfused where they could be an embolic event. Um, normal motor function again because of lack of the fusion and chest pain. Because again, um, of the lack of fusions of hearts and flung bruising, which can suggest bleeding inside of the abdomen. Systemic symptoms that we will have always have to ask a bite on the wrecks here. So, like with the decreased appetite or went nations know, eating, weight loss, nausea, fatigue, fever and confusion. Um, when we ask you about the pain, I hope that, you know, by now do we use the Socrates s. So we ask about this site onset character, radiation, any other dating factors and exacerbating factors. Um, this severity onda timeline of the pain and for this patient's and then pulls in past medical history and past surgical history would be any perfume aneurysms known abdominal aortic aneurysm, renal stones. Because that will be one of our differentials. Gastric ulcers is again because it can present in a similar way as ah g i preparation called by no, sir. IBD and I bs. And we also want to know if they have any family history off abdominal aneurisms. Want to know if they smoke or if they drink. Um, and was there exercise tolerance? All right, So our patient 75 year gentlemen and the history of his presenting complaint was sudden onset back pain and collapsed two hours ago. But he's now responsive. Be able to speak to him. He feels unwell, and he's vomited three times. His past medical history is significant for high cholesterol. He had a heart attack three years ago. He has osteoarthritis and renal stones. He smokes, um, a lot. He does have a 20 pack your stomach in history. He's a moderate drinker on do his exercise tolerance this poor because of his osteoarthritis. Um, even though he's 75 he didn't attend his abdominal aortic aneurysm screening 10 years ago because he missed his invitation. All right, so we examined him. We use the 80 approach, we check his GCS. Um, so we we have to examine, uh, depression is speaking to us on. He's not confused. He's able TOBA commands, and his eyes are responsive to just maintain you sit down. His GCSF be 15. We want to know his urine output because, as I did say before, if the kidneys not perfused that we know you're not put and that's important in a patient with a suspected of done the aneurysm on, we want to examine, examine his abdomen, check for any masses distention um we're gonna megaly want to perform a very for neurological exam and approved for blast their exam. So in this case, our patient is confused. Um, so his GCS is not 15. Is these 14 out of 15? Um, he's sweating clammy, and we examine his abdomen, and there is a pool. So tile and expansive old mask built in the abdomen in the very humble, like a region. So just above the umbilicus. Okay, So when we put the hands on his tummy above the A bucket under like us and we could feel the pulsations, our hands normally would go up if you just feel the aorta. But our hands go upwards and outwards. So this is suggestive of the pool. So positive and expansile mass. His BP is 98/17. Um, but we've already given him loads of fluids, and his heart rate is 110. So he is, um he does have some symptoms of a shock. His saturation is 91% on breast special. Ages 26 is temperature's 36.2 and his blood sugar was normal at 5.5. His urine output output. It's full and when it performed the peripheral neurology one last year exam and there was reduced power in his lower limbs. And the Peter pulses are quite faint and the legs are cold to touch, so it just suggests that he does not is not getting enough perfusion to his legs. It's the way to monitor the stations. Um, as he is very unwell. The most important thing is going to be t stabilize him. So we're going to follow the a two year approach. So we're going to assess his airway and act on anything that we find along the way. So our patient had the, um, oxygen saturation of 91% so he's able to speak. So we're not worried about is the way, um, there are no added signs, but his breathing his respiratory rate is increased and his oxygen saturation is 91%. So we'll have to acting that his hemodynamically unstable. So we'll have to give us some truth in four deaths, and then we have to follow that. This is, um, could be their 80 assessment following the disability and exposure steps. And in this case, if you're a junior, any see a patient like this coming through. You have to escalate almost immediately as your resuscitate intubations. So this is This is quite challenging because ideally should have senior support from the very beginning. But this is something that happens on the wood. And he happened to be doing me on the person there. Then you have to escalate as you resuscitated the patient. Okay? And the patient might need emergency surgery, but it's important to get senior input as soon as possible. Correct. So because John is able to speak to us and his book better. Still low aunts on his heart rate's still high, but we need todo some urgent investigations to help us decide on what exactly is that he needs. Okay, so I'm terribly sorry for that. Um, but you can see So his investigations, we're going to do some blood tests, including group and safe, because he might need surgeon surgery. And then you can see, um, this is John's abdomen. So we see this and we decide that it's probably best that we do a CT for him, So don't our bet side, But so I tests. So we did the the blood test that we see GI. Um And then we did there fast scans and ultrasounds gun by the bedside, which showed some blood in the abdomen. And we can see the various evidence of bruising in the abdomen. And we decide to do a CT scan because John is fairly stable. And as you can see on the CT scan, here, there is, um, this is the aorta, and there is an aneurysm in here which is leaking. All right, So that means of John needs surgeon input. So what we're going to do for him? Um, as I did say, we're going to do the 80 assessment on going to escalate as soon as possible. Right? So we need to call our register as soon as we can. Or we can resuscitated a shin. That's the nurses to get in touch with with our register immediately and put out a period rascals. So you can get all the help that you need. So we're going to give the patient high flow oxygen Bayan only breathing mask. We're going to teo it access. Um, so the patient we need to large bore cannula for a basket access in both arms, and we're going to cast arise the patients because we need to be able to compensate as you're in that foot and quite a n'importe. Nothing in managing abdominal aortic aneurysms in emergency setting is that we have to allow permissive hypertension. So normally, when the patients present with low BP, we want to increase their BP to to a normal limits. So over 120 let's say But in this case, because the abdominal aortic wool, it's fragile on. But we know that there is a perforation, so we don't want to put more strain on this tribal aortic row. So we are going to aim for the permissive hypertension or BP. Less than 100 tea not made the bleeding any west. Um, we sent some urgent let's so full blood kind electrolytes and clotting. We also did a group and safe and cross matched over six units off packed red blood cells. Because this patient most likely will need a surgery Aston, it's possible. So we need to have, um, at least six units if not to 10 or more off red blood cells and other blood products. T to be able to resuscitate this patient properly on those patients. Most likely, we need to be transferred to a specialist Vascular unit. Um, for the emergency on your repair. So is there a rule of thumb intubations stable? We do a CT angiogram to determine days they're suitability for the end of vascular treatment. If the patients are unstable, then we have to immediately transfer them to feel better for open with that again. That depends on where you're at. If there is a vascular department in your in your hospital. And also, if we if the patient does not have any past medical history off, I'm gonna abdominal aortic aneurysm. Sometimes this is a very difficult decision to make because we might be going in blindly if we if we don't do a CT so busy, this is a decision that you're senior will have to make. Okay, so it ruptured aortic aneurysm, which you can see in here on the right hand side of the screen. And so if you conceive, um, here there is ah, lack of continuity in the aortic wall, and there's blood leaking into the abdomen. Okay. The ruptures of the abdominal aortic aneurysm cause about 3000 deaths a year in the UK and the risk increases exponentially as the diameter of the aneurysm creases. Um, most of them. And this is the case in here on this light rupture posteriorly into the retroperitoneal space and then most often hemotomas forms and the bleeding is contained. So that will make the patient stable enough to get to the hospital and get see the operating room, even know depression. Maybe unwell. And that has a better prognosis If there is an anti rebooked, Um, there's no hematoma information. There's free blood in the abdomen, and it just continues to bleed. Those patients most of the time don't even make it to the hospital, and they unfortunately passed away. The risk factors for having aortic aneurysm on for the rupture, um, actually in particular. And the risk factors that increase your risk of rupture is smoking hypertension on being a female on the classic Try it. Ruptured aortic aneurysm is going to be flung or back pain. So one of the team, um, with hypertension and a pulse total abdominal mass. So enjoying the patient that we are looking after it a moment he had this classical try it, so he had back pain. He did have hypertension. And we did feel the bulls a tile abdominal mass. So he presented with this classic glass could try it. And, um, other symptoms can be any signs of shock and syncope. So collapse and abdominal pain or loin pain and abdominal aneurysm. Um, aortic kind of no aneurysm is internal. It, in general, defined as a, uh, abnormal dilatation in over the abdominal aorta. Um, greater than three centimeters. It's, um it is seen in one in 17 men who are aged over 65 on The cool is is for having aortic. Abdominal aneurysm are mostly atherosclerosis and trauma infection or connective tissue disease. So I think in in our practice in the UK after a screw says the constipation and the static plaque deposition just linked with just caused by the the cardiovascular risk factors a little about patients have, um, such a smoking hypertension hyperlipidemia. Um so those patients are dressed of the loving triple A, we call it so the other risk lactis are increasing age, family history and male gender. So people here are males are more likely to have a domino took aneurysm. If you haven't abdominal aortic aneurysm on your female. That New York Higher risk of a rupture. Interestingly, diabetes is a negative risk factor, so it's a protective factor. So people with diabetes don't have less triple A's than the general population, and we still don't quite know why. That is the case and the symptoms of Triple A. Um, it can be asymptomatic. So it can be an incidental finding on the screening, Um, or just on a CT or another scan done for a different indication it can present with abdominal pain, back or low in pain or leg. Like this. Kenya, because in the sock is you can see in here very often they were from by form. You have little clots forming. And even though the bloodiest of flowing, those there's a very chaotic flow inside of the on your is most sac on with the clothes from here can then be flicked it to the water is supply the legs and the patient can present with with them ischemia so essentially like off a fusion with blood to the legs. Okay, so I just wanted Teo quickly tell you a little bit of a D anatomy off the aortic aneurysms. So if you look at the picture on the left and this is how to healthy your dose supposed to look like so you have your if you just look in here. So this is the the human body. And then, um, when we look in here, this is the aorta, okay? And these are the renal branches, and these are the common idea car trays. And on the other side, you can see the abdomen, your Diovan aneurysm. So again we have our aorta, and then the aneurysm, and then that is very close to the renewal vessels in here. Most of the aneurysms in the ureter are fusiform. Conceded. Yeah, So it's gonna expansion equal expansion in all directions. And sometimes we see secular aneurysms, but you can see in here it was like an outpouching on do that is seen more often in case of trauma, um, or infection so that the aneurysm that we're talking about mostly is going to be if you sit for my aneurysm, and then there could be different locations when the word, uh um underwritten develops. So you have a super reno, so it's above the green are trace pottery? No. So it's just maybe the, um and same with juxtarenal. So the PARARENAL will involve the renal arteries. Juxtarenal is nearby, but it doesn't affect the renal arteries. As much infrarenal on your is, um, so these are your form, ain't I Piss in terms of location and in the UK because we know that, um, abdominal aortic aneurysm is found in one and 70 men over the age of 65. We do have a national abdominal aortic aneurysms cleaning program on the way the program works is that all men on their 65th birthday get invited to have a one off abdominal scan off their abdominal aorta. Okay, so get the ultrasounds done. Um, and this a one off Unless we find they, we find an aneurysm. So and the program has strained that there. There is a 50% reduction in on your asthma related mortality. Um, for people who do take part in the screening, um, 1.1% of people he attend the screening are diagnosed with, um, trip blank and that treatment in his office to patients who have the abdominal aortic aneurysm that measures over 55 millimeters and I says You're a plain 32% of those screens on in general, we consider surgery if it's over 5.5 centimeters, or if it's expanding more than one centimeters a year. So it's kind of self. Um, it's kind of simple, so that if the aneurysm is over 50 55 millimeters of 5.5 centimeters, or is that this fresh world? W for treatment? If it's expanding rapidly, we offer treatment. But what do we do for patients? He's and who do you have? Aneurysm. But they're smaller. So any, um, abdominal aortic aneurysm, since that measured less than 55 millimeters are monitored with a special order, signed a duplex ultrasound. So if their aneurysm at the first screening meeting is between free 0.0 to 4.4 centimeters, they get older, assigned once a year from from then on. If their aneurysm is 4.5 to 5.4 centimeters, they get older assigned every three months. So this is something you can always look up. This is not something that you necessarily have to remember, but it's just, but it's just interesting to to know what happened to those patients I am on, um, those patients who do have aortic aneurysm in the abdomen. They have a free percent risk of cardiovascular tallit e. So the most important thing that we can do for them if they're not yet of the fresh one for the operation that the very important thing to do is Teo reduce their risk practice. So we need to offer them smoking cessation advice. When you Teo control the BP long term on, we need to make sure that they're on the best medical therapy. So for those patients, it will most likely to the statin an aspirin. And we should advise them t lose weight if they are overweight. And the surgical management, Um, for abdominal aortas, Um, there are two main approaches. An open surgery on day endovascular re surgery. So on the left hand side off their off the screen, you can see the open repair. So essentially we opened a whole abdomen. It's a big surgery, and that takes quite a long, long time for the patients to to heal. Afterwards, Um, they have a clump above the aneurysm sac and at the bottom in here on common. I like our trees, and then we opened on your is most acne. We put a graft like achy, a graft in sight and only suitor, um, the aneurysmal unreasonable sac, which just slightly excited and reduced around a cheap graft. And then we have to close the abdomen and then do everything else so in emergency setting. And if the patient has a known Triple A and we don't have an update CT scan to see if they're suitable for endovascular repair, they will go to have an open repair. The end of vascular repair. Um, has a lower, um, it's less invasive, essentially. So, as you can hear, see here at the bottom of the screen, this is the patient's growing. Um, the way we put in the sense in the endovascular repair is by using the common femoral artery. So we we make a small incision in the groin, and then we put all the catheter east and the graft for this little cut in the groin, and we can do cars on both sides. So then we can put all the all the parts of the aneurysmal off the off the graft inside it. Um, but I think essentially at know all the patient will be suitable for endovascular repair. Um, so this is this is a decision that has to be made based on in case, um, individual case basis and their postoperative management for those patients. As I did tell you before, Um, if the aneurysmal sac is expanding or if the abdomen aneurysm is leaking, then there is a risk of that. Essentially all of their major organs, including your brain, your kidneys might not be refused. Well, so after a surgery, like, um, an open or intervascular a pair off the triple A, we have to do regular neurovascular observation off in all four limbs to see if there is good perfusion. You wanted to urinate, fits to check. The kidneys are okay. We do monitor patients consciousness state or a GCS. Um, do you monitor dead the brain perfusion? We're aiming for a normal BP, and we, as after every surgery, have to monitor for any bleeding for surgical sides. Um, any opening off the the wounds on four dose patients? We do a CT on day two. Um, the check if the if the graft is in the in the right position Okay, So I I told you a lot of information, so we're going to do a quick recap a mental meter. So you have your, um you have your code. If you just go Team menti, we're going to go for some questions. I wait for everyone to join. And the first question is, um, at a routine screening, um, older signs gone and, uh, symptomatic mail and has a 4.1 centimeter abdominal aortic aneurysm. How often do you think he needs that surveillance gown? I'll let more people join because we're going to do a couple of questions in the road, so you're not going back and forth. So 4.1 sent to me toe abdominal aortic aneurysm and they first routine screening. How often does the patient needs to come back for his old resigned? All right, so great Majority thinks it's every year, and I hope this is going to work for me on that as a crackdown set. So, um, it's every year on day and we, um essentially, if it's 4.5 to 5.4 centimeters, would do it every three months. But if it's less so free and and high, and that includes 4.1 will be every year. We're done, guys. Next case is a 75 year old male who presents with known aortic abdominal aneurysm. And he presented a collapse. He is hemodynamically unstable. So was the best Definite if management for him. So the options are open repair and the vascular repair, a CT scan or fluid resuscitation. All right, So, well done again. Majority of you got the answer. Correct. It's an open repair. Um, so in this question, um, that the buzz words are that he has a known Triple A. He presented the collapse on that hemodynamic instability. So he's ah, he's definitely fit enough for the CT scan. And we we can't do an end of our ask every bear with me. I'd a CT scan to help us plan everything. Um, and another buzz wouldn't in here. This was the best definitive management. So definitive management is essentially how what do we have to do to ultimately help this patient? So this is why the answer is open repair, not fluid resuscitation. Because, yes, we'll have to do. The fluid was a station at the beginning, but a definitive management is going to be the open repair for the patient. He has another triple A and comes in over collapse in the human dynamics instability. We're done. Right. So now we have, Ah, a 75 year old male with unknown Triple A, The same patient. He presented the collapse, and he's human, dynamically unstable. But this time was the best initial management for this patient. So we have four different options. All of them suggests that we should use the 80 approach. And then do we aim for permissive hypertension? Normal tension? We don't fluid resuscitate, um, resuscitate. But there's no look. Better target. Awesome. Um, so once again, you guys got it mostly right? So well done. Um, Innovations, who has a known Triple A and presents with that hemodynamic on stability and collapse. We're going to do a TSS mint. I'm going to aim for permissive hypertension, says I did say we're going to try and save this fragile aortic well, and this is why we're going to aim for the BP less than 100. But obviously you need to see your support for that. And it's only after it a surgery that we aim for normal tension. So 120. And they're about it. So this is still a good pressure. Well done. All right. Night. What is the classic? Try it. Seen in, um, aortic abdominal. Um, aneurysm a rupture. The last option is chest bass, or you cannot spell perfect femur people. All right. So, again, you guys go to right? So I'm glad that that you are listening. Um, the classic triad is going to be abdominal or back pain or flank pain. Um, over pulsatile mass and hypotension. It's a low BP in those patients. Okay. Perfect. All right. So a 65 year old month, um, attends a triple A screening. Ultra signed, and he does have a a nine year. Isn't that measures free 90.7 centimeters? What is the most important management at reduced his cardiovascular risk? They're all they're important. But if we can think off what might be the most important if you were to pick too fabulous. You guys come before this is correct. And so because we know that high high cholesterol and high BP increased risk off, um, off the having an aneurysm in on. But the the aneurysm rupturing. Then we'll have to make sure that the patient's cholesterol and BP controlled obviously the patients Diabetic long term is real important, Thio and sure, the blood supply, because control is adequate as well. Okay, so and I'm really sorry for flicking back and forth, but you guys have to bear with me or it. So just teo been, it's off our first case. Um, I told you, they're two different types of a pen of the abdominal aortic aneurysm and open repair. When you put a chip graft or an endovascular repair when we put this, um, this chorus material kind of ah, kind of a graft in, um, which you can see in here. So this is the graft with ministrations to make sure you don't close off all the all the branches coming off the aorta. Onda has few parts says you can see in here on the graft you have the main body, which has, um, one side of it is like long tries is like jeans and the other one's short like you kind of made shorts off the one side of your over tries is, and the way we put it in is we put the main body with their long tracer Bart in, and then we put their the rest off the graft separately. So there are some problems that the base is going million kinda. And we call those and the vascular leaks and and that's that happens when there is an incomplete seal on. Essentially, the blood can still go into the aneurysmal sac and disaster against it happen. And so they're five different types of what I would just quickly mention them. But I don't think there's, um there's any need for you to notice in detail, but you just have to know that some of them, um, are leaks, um, under high pressure, and those will need operations straight away. Okay. All right. So second case, this one's going to be shorter. I promise. Ah, their case is on a a 65 year old male he presents with a sudden cold and painful right leg. Um, she's unable to wait there, and she has this tingling sensation in her leg. So what do we think could have happened? The differentials in here could be chronically Ms Kenya. Acute limits, Kenya Acute DVT. So acute clot in one of the veins off the legs, Um, spinal cord or peripheral left compression because she's this tingling and pain, um, or compartment syndrome. So in this case again, they use the same approach going to take the history. We're going to examine her using a to the approach. We're going to do the investigation, starting from bedside for bloods and radiology. I'm going to be, as we have already done, think of some differential diagnosis. So in this case, I'm Anna tells us that three hours ago her leg became suddenly cold and painful, and the pain is mostly felt in her 4 ft. So at the most distal part of your foot, um, and she's unable to wait back and her entire legs tingling, Um, her past medical history includes intermittent claudication at 50 m. So intimate of publication is this, um um this is seen in essentially pain eater in Europe cafs or in your buttocks. And it's seen in patients who have peripheral vascular disease in particular perfor zero disease. Because when they're walking, um, their blood supply can not much the demand, um, and that the muscles essentially are start of oxygen. Start of blood and the patients start getting pain and that stops them from walking. So she gets intimate implications or just pain in, um, in handcuffs and 50 m. So she has to stop. And and this is something that she's had for a long time. She had a heart attack three years ago, not five years ago. Um, as I did say on the slide. She had a mini stroke two years ago, and she's a type two diabetic. We're going to examine her. We're going to use a two year perch again. We're going to do a peripheral vascular exam, paying special attention to pull, say's temperature of the leg color, capillary refill time and then the swelling ever go to do it through from, you know, logical exam. Um, looking t to see if her sensory and motor function are normal. All right, so we examined her. Those are her feet, and as you can see, the right one looks pretty dodgy. Um, so she's alert and awake the right leg. It's pale, and it's very cool to touch, were unable to see what the couple of refill time is on the right, because essentially one repress cause what you want to see. In a couple of refill times, you press goes white, and then it kind of goes back to your normal skin color, and he kind how long it takes to get there. Um, so we're unable to do that because the food is so white. And then she doesn't have any sensation in there, most distal part of her foot on day. She even if she's not moving, she's not complaining of a pain in her leg. Um, the motor function is mildly reduced, sir. She's able to move her toes, but just about it. And she can move her uncle. But the range of motion is slightly reduced. We do the arterial arterial do blacks. Um, so we use this. We call hand, held the Doppler machine by the bedside. We put some jelly on on the artery and we put it on and let it sit for any signal. So in her case, there's no signal audible in any of the arteries off her leg. So what? There's some other investigations we're going to do. Well, we have to do the bloods. So, as always, we're going to do full bloods kind. We're going to do? Use the knees to check for electrolytes and the renal function. I'm going to look at the liver function. Um, crp. We're going to check for some clotting. So does the best have any clotting disorders? That will mean that she's moved like you have some clots that will stop the blood from the leg. We're going to check for lack dates. Dose. As for tissue ischemia, So essentially, when the tissues don't get enough effusion, the lactate will go up. Would do a group and safe Onda cross much in case the patient needs needs an urgent surgery on. We're going to do it from a fairly a screen to see for any clotting disorders they could have caused that we're going to do an E c g Um, and in this case, the patient is in Sinus rhythm. But she's talking Codec. We're going to check a urine, but there's nothing on her. You're in debt, and we're going to do a duplex ultrasound. Um, on eventually we're going to do a CT angiography. So in the case of this patient, you can see a nice free the CT reckon struck shin off her arteries on on the left side is the order in the center. And then we can see the common, um, coming idea AC. And then we can see the common femoral. And then we have the, um yeah, the coming from the artery here. And then it nicely becomes that that profound. The family's in the superficial femoral artery here, but then when you look on the left, there's nothing here. There's something that's that's obstructing to flow on the right side and then in here we can Nice to see what level it, uh, it's still to pacifying. So that will help us with that with this surgical planning. So I the patient, um, for me the title off the top has already given away presents with one of the vascular emergencies, which is acute Lynskey me. So it's ah, surgical emergency because it threatens the leg viability. Essentially, I you probably have heard people say that time is leg in that situation and the surgery in patients with severe acute limits, Kenya need the surgery even six hours. Teo say they're limb and in some cases, to save their life. And so it's ah, it's caused by sudden decrease in the profusion on the classic presentation is in the morning cough six piece, Which would you conceal here on the on the little diagram to the patient presents with with pain, paralysis. They don't have any pulses, and there's parasthesia so they can feel it touching them. There's lots of sensory function, the legacy pale, and it's perishing. Lee cold on The reasons why some people might get acutely, um, ischemia is because they haven't endless. Essentially, there is a clot somewhere. Then it travels elsewhere. So that's, um, and ambulance. And so people who have a prosthetic heart valves or abnormal heart rhythm such as a defibrillation. People who had a heart attack and have some from us inside the heart, or people who have aortic aneurysm with those little front by the I told you about it, I'm inside that you're in the Aneurysmal sac can have the the ambulance that travel somewhere on, because is Thursday crease left a fusion, or sometimes people can have a from this developing in situ, so in the essentially in the same side would cause occlusion, and that is seen in patients. He have peripheral arterial disease. With this constipation and after rumor plaques for a while there vessels. So in the heart, if people have have a plaque will present with angina, or the patients might have, ah, myocardial infarction and in the legs the same process will present with a kid limits Kenya. If it's if it's like if they're plaque, builds up enough and then ruptures to include the blood flow. So essentially in this patient, she's had a chronic, um, peripheral arterial disease. And this is evidence by her intimate implications, this pain when she walks. But now she has developed acute on chronic Lyme ischemia because now all of a sudden just painted rest her legs pale and she needs. She will essentially need us to do something that's safer. Leg. So what are we going to do for her? We're going to use an 80 approach, and we're going to escalate a senior stress away. We're going to give her high flow oxygen IV fluids. We're going to catheterize her, and we're going to aim for a strict fluid balance. I'm an important thing in here is because there is an obstruction. We have to make sure that the blood is thinned, so it doesn't get Wes. So we're going to put her on IV heparin infusion as soon as possible and the reason why we're putting her on heparin infusion? Not on. For example, low molecular, low, low molecular weight heparin. Is that IV heparin infusion? It's easily, um, reversible if need be. So this patient needs to go to surgery. We don't want to risk her getting a high dose of low molecular weight heparin and then asked having toe weight to be able to operate so she doesn't bleed from elsewhere. So giving I be happening easily reversible if needed. Um, and the bases. We need surgery and six hours. Unfortunately, sometimes the limb is nonviable and it's afraid to life. So those patients, my knee amputation in there worse case scenario on, we have to, um, we have to monitor for refuge in injury. So in dose patients one, when the blood flow is occluded for it for a long time, um, and then the blood starts flowing again when we repair it there at risk off, um, kidney injury. On day a compartment syndrome because when there's no blood flow, bluff swelling develops, and then the muscles mark my starts dying off and everything is swollen and there is a risk of a compartment syndrome. So the surgical management, um, in this case, there are some options if if it's an embolic cause. So there's a quote somewhere in the Troubles elsewhere, Um, we can do an emergency and electively so removal off this, um, embolus with Forget e capital so you can see it at the bottom and here and talk to you see the tips. So it's essentially a long catheter that we put in the vessel, and it's deflated. So it's same diameter for right when we put in, and then we inflated. So it can. It increases in the day. I'm ataxic and see in here there are different sizes, and then it pull it right. And as you do essentially was an embolus. You see something like that's then a number less coming out, Um, and then your other options is local intraarterial license or bypass surgery. Um, is the bypass surgery essentially, If let's say there is a new occlusion here on the on the picture, you'd want to use a vein graft or prosthetic graft. Teo, join Payton vessel the Peyton Vessel essentially bypassing to obstruction. So again, same. It's in in the heart going to do a coronary. Arterial bypass grafting were just, um, connecting to Peyton bits of the off the arteries to bypass the obstruction. If it's a from about exercise, Uh, from what a course rather we can do an angioplasty. Um, so we can you can see in here we can put this special balloon inside of the of the vessel and kind of score. Sh the plaque that caused the on the occlusion and that would increase the damage of the vessel. Or again, we can do the local are to realize is over by bus surgery. It's the post of monitoring for those patients. Leg You learn your vascular observations of the affected limb. We have to make sure that whatever we have done is working in the blood is flowing to the leg. We're going to keep them on the heparin infusion because we want to keep their blood thin so they don't, um, include again. And then we have to look out for those complications by assessing the patient regularly and doing regular blood tests. So those patients are at risk at off myoglobinuria essentially as the um, my blow been is released from the muscles, the muscles of damage because of the lack of perfusion. When that gets filtered by the kidneys, the kidneys can be damaged. And we have to look out for compartment syndrome. Um, so classically pain on passive stretching and intense massive compartments and the acidosis or Heiberg Kaleena again. That's kind of linked with a tissue ischemia or lack of confusion. And the long term management for those patients. Maybe reduction of cardiovascular risk practice. So Samos, with triple A weight loss, smoking cessation, regular exercise, they should be on an antiplatelet therapy long him aside, aspirin or clopidogrel, Um, and then the long term would have to investigate it. Possible causes. Those are you said previously we might think about from a feeling, a screen or a basket. I just green. But this is something that's not going to be done in the acute. The of the admission. It's just something that we need to think off in the future, all right, and before we may want Teo may want to the summary. I have just a few last questions for you on, but we'll be done so. Which of the following guys is not a risk factor for acutely Myskina and would have one more question after that and we'll wrap up All right, so very well done. COPD. It's not a risk factor for acute limits. Kenya. I'm having a metallic help up or abnormal heart rhythm such as atrial fibrilation Or smoking is a risk factor for acute Myskina. And the last question So the patient was treated for acute ischemia, then becomes hemodynamically unstable on their SCG shows. Ventricular tachycardia. What electrolytes should be checked. This is a bit of a tricky question door. It might be so which electrolyte will be deranged in patients of acutely Ms Kenya and potentially compartment syndrome that could cause easy tree changes such as ventricular tachycardia. Fantastic guys, it is, um it is potassium, those patients, um, when they're scheme, it and the masses are damaged. They will release, um, high minds of potassium and that puts them at risk off ventricular tachycardia. Well done. We're going to be done in three slides, hopefully important ones. And so, just to recap, most abdominal aortic aneurysms are asymptomatic. Um and I found incidentally, and we do have a screening program. Um, for everyone at the age of 65. And surveillance is with older science gun. Um, and their CT scan is required when we think about the surgical planning. Um, if somebody has a small abdominal aortic aneurysm, their risk factor reduction is crucial for them until they get to the fresh hold off where they need surgery. Um, if the patient is symptomatic or unstable, we have to escalate immediately and do the 80 assessment and then acutely. Myskina most often present with seven ounces of pain and power of the leg. Um, CT angiography is the gold standard investigations for a cream ischemia. So this little scandals So where there is a level off, their off, the occlusion visible, and the surgical management will depend on it. Urology on day told you some different options and postoperative it. We have to monitor for re perfusion syndrome Heiberg, Lena acidosis, and we have to identify causes for acute illness Kenya and optimize what we can do. Essentially, did the modifiable risk factors, Um, and just to remind you, you can access our free surgical webinars on, um, mind a bleep dot com forward slash surgery. We have added some new articles recently, so please go and check the mind on. Most importantly, please do feel in the feedback form because we want to know what you think and constantly make our own. Ah, we're sessions better. Um, so you get exactly what you need. Um, on there's a link. Well, I hope it does work, but I might put it in there. Phase the blinkers? Well, in the second, um, and the next session, um, next Monday is going to be on ear, nose and throat, common presentations and some emergencies. And this is going to be a pen. Ultimately, it, um, session off the surgical minded bleed serious. So we're going to be saying goodbye soon, but I hope you enjoyed it. Please come. The QR quote opposed their the feedback ling in the chat in a second as well. Um, in the meantime, do you guys have any questions? And if you do, I can check the night on Facebook normally. All right. Are there any questions? Let me copy the feedback link and also forever and ever, and he's interested and bind. A bleep is expanding, so we're not going to go for long, but we're going to create a specialty Specific, um Webinars. So the surgical sessions are now going to become loads of different subspecialties because it looks like you guys enjoyed it. So good. T launch launch a lot of specialties. Yes. Question about the infusion of heparin. Let me have a look. What year? Oh, yeah. We're not waiting for different videos. Going to take somebody still pretty during room. That was not a suggestion, ever. It's just if we're taking blood, why is the take them for a different before yesterday? But this is something to do later on. Yeah, but ask you, um, would be the main offender. Ah, yeah. Okay. So that that fasting is going to remain the main electrolyte deranged here because of the compartment syndrome and esquina. Um uh and then not to confuse things, but yes, casting click in eight is the is the first of treatment for and hypercalcemia. But this is for another time. Um, Andi, do you guys still have a question about the heparin infusion? I can't see it. Yeah. Oh, does of heparin given initially after the surgery. So, um, the dose of heparin and never trust him. I'll be different, essentially, in the trust with our For example, we use a, um, a blood test called anti 10 a, um, factor level because the heparin will target, um, factor today. Essentially Want to see if it's working well enough by assessing the levels off factor today in the blood. And the way we do it is, um there's a hospital particle, and we're aiming at defector 10 a level of 0.3 kids. Europe in seven. Um, there is this, um, you have to look at the look at the prescription. The hospital Essentially, um, we give there's a specific amount of units by kilograms we give to patients, and then we take a blood test for hours after and then depending on the um on the level of factor on today will either give more heparin or less heparin or switch it off or give a bonus. But there is a very specific cost, the vertical, which I'm not sure if you can Guys access online, but it will be in every hospital trust if you look for, um, uh unfractionated heparin infusion, dozing. And whenever I do it, I have tombo blood test come back, have to go and reach for the guidance again to see what I'm to do because