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นพ.ประสิทธิ์ วุฒิสุทธิเมธาวีนพ.ประเสริฐ วศินานุกร
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PRASERT VASINANUKORNPRASIT WUTHISUTHIMETHAWEESONGKLANAKARIND HOSPITALPSU, HATYAI, SONGKHLA
Scenario 1• ผู้��ป่�วยหญิ�งไทยคู่�� อาย� 50 ป่�• Refer มาจาก รพ.สตู�ลด้�วยเร� องขาท"#งสองข�างอ�อนแรง• 4 ชม.ก�อนไป่ รพ.สตู�ล (1 3 .0 0น .) ผู้��ป่�วยไป่ก�มๆเงยๆเก(บหอยแล�วม*อาการเจ(บหล"งข+#นมาท"นท* ร�วมก"บม*ขาท"#งสองข�างอ�อนแรงและชา จ+งไป่ รพ.สตู�ล• Underlying: ญิาตู�ให�ป่ระว"ตู�ว�าเป่.นโรคู่ห"วใจขาด้เล�อด้มา 5 ป่� ตูรวจพบท* คู่ล�น�ก แตู�ไม�ตู�องก�นยา ???• No history of drug allergy
Physical examination (Physical examination (จาก รพจาก รพ..สตู�ลสตู�ล))
•V/S : BP 130/90 mmHg, PR V/S : BP 130/90 mmHg, PR 90/min90/min
•GA : consciousnessGA : consciousness•HEENT : not pale, no icteric HEENT : not pale, no icteric
sclerasclera•Heart and Lungs : WNLHeart and Lungs : WNL•Abdomen : soft, not tenderAbdomen : soft, not tender•Back : tender at L2-3 area, Back : tender at L2-3 area,
no stepping no stepping
Physical examination (จาก รพ.สตู�ล)
• E4V5M6, pupil 2 mm BRTL• No facial palsy, EOM full• Motor Right Left
– Upper V V– Lower 0 0
• DTR Right Left– Upper 2+ 2+– Lower 0 0
Physical examination (จาก รพ.สตู�ล)
• BBK : negative• Clonus : negative• Stiffness of neck : negative• Pinprick sensation : loss below
L1 level• Sphinctor tone : loose• Bulbocavernosus reflex :
negative• Eyeground : sharp disc
Problem?Problem?Differential diagnosis
ManagemenManagement?t?
Scenario 2ผู้��ป่�วยชายไทย 72 ป่� ถู�กน1าส�งห�องฉุ�กเฉุ�น โรงพยาบาลสงขลานคู่ร�นทร3 ด้�วยเร� อง ป่วด้ท�องมาก ป่วด้หล"ง และเป่.นลม ระหว�างน" งคู่อยตูรวจเล�อด้ เพ� อมา FOLLOW UP
P.H. KNOWN HT, DM, SMOKER
P.E. SEMICONSCIOUSNESS, NOT PALE
PR 80 BP 100/80 RR 18 SAT 97%
Scenario 2
CHEST - HEART O.K.
ABD - SLIGHT TENDER
- MILD GUARDING
บร�เวณ Rt. SIDE ABDOMEN & FLANK
- NO DEFINITE MASS
Problem?Problem?Differential diagnosis
ManagemenManagement?t?
Causes of Human
DiseasesPATHOLOGY : CONGENITAL, INFECTION, TRAUMA TUMOUR, DEGENERATIVE DISEASES
NATURED : ENVIRONMENT, DISASTER
MAN MADE : CRIME, WAR, SELF-INFLICT
VASCULAR PATHOLOGYARTERIAL
ATHEROSCLEROSIS
ART.OCCLUSION
EMBOLI
THROMOSIS
DISSECTION
ANEURYSM
TRAUMA
VENOUS
PHLEBITIS
VENOUS THROMBOSIS
PULM. EMBOLISM
A-V FISTULA
TRAUMA
VARICOSITIES
VASCULAR EMERGENCY
INVOLVE- ALL PART OF THE BODY
- ALL SYSTEMS, ORGANS
- SYMPTOMS & SIGN VARIES
- SAME ACUTE ONSET-RAPID PROGRESS
- SAME PATTERN OF PATHOPHYSIOLOGY
VASULAR
EMERGENCY
TRAUMA
NON-TRAUMA
PENETRATINGBLUNTIATROGENIC
ARTERIAL OCCLUSION ATHEROSCEROSIS DISSECTION ANEURYSM VENOUS THROMBOSIS PULMONARY EMBOLISM ARTERIO-VENOUS FISTULA
EMBOLITHROMBOSISSPASM
SUPERFICIALDEEP V.
VASCULAR EMERGENCYREQUIRE EARLY DIAGNOSIS AND
MANAGEMENT
ONLY 3-5 MINUTES WILL RESULT IN DISABILITY OR DEATH
EARLY CONSULTATION AND TEAM APPROACH IS REQUIRED
DETAIL KNOWLEDGE OF PARTICULAR DISEASE REQUIRED
METHOD OF DIAGNOSIS AND TREATMENTS VARIED
EP SHOULD KNOW ADVANTAGE AND DISADVANTAGE OF EACH
EP SHOULD KEEP IN MIND IN EVERY PATIENTS VISITED ER
COMMON VASCULAR EMERGENCY IN THAILAND
(PERSONAL, 35 YRS, SINGLE VASC.SURGEON, 12 MILL.POP,14 PROVINCES)
VASCULAR TRAUMA
ARTERIAL OCCLUSION
RUPTURED ABDOMINAL AORTIC ANEURYSM (AAA)
CORONARY HEART DISEASES
RUPTURED THORACIC AORTA – TRAUMATIC
VENOUS THROMBOSIS – PULMONARY EMBOLISM
COMMON VASCULAR EMERGENCY IN GENERAL
CVA – TIA, STROKE
CORONARY ARTERY DISEASES
AORTIC DISSECTION
RUPTURED AORTIC ANEURYSM
THORACIC AORTIC TRAUMA
COMMON VASCULAR EMERGENCY IN GENERAL
PERIPHERAL VASCULAR TRAUMA
MESENTERIC OCCLUSION
PERIPHERAL ARTERIAL OCCLUSION
VENOUS THROMBOSIS
PULMONARY EMBOLISM
MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMSSYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE
CNS - TIA, STROKE
CVS - CORONARY, DISSECTION, ANEURYSYM
EMBOLISM, THROMBOSIS, VENOUS DIS.
THORACIC - DISSECTION, RUPTURED, ANEURYSM
MANIFESTATION OF VASCULAR EMERGENCIES BY SYSTEMSSYSTEMIC MANIFESTATIONS OF VASCULAR EMERGENCIE
ABDOMINAL - AAA, MESENTERIC OCCLUSION
- AORTO-ILIAC OCCLUSION
EXTREMITIES - EMBOLISM, THROMBOSIS
VENOUS - DEEP VEIN THROMBOSIS, PULMONARY
EMBOLISM
PATHOPHYSIOLOGY(1): ARTERIAL OCCLUSION : EMBOLIACUTE ON SET OF SYMPTOMS &
SIGN (5Ps)
PAIN
PALLOR
PARESTHESIA
PARALYSIS
PULSELESSNESS
SOURCE – MI, MV with AF, HT
ELDERLY MALE > FEMALE
NORMAL COLOR SKIN NAIL HAIR
IN OPPOSITE EXTREMITY
RAPID ONSET SYMPTOMS & SIGNS
PATHOPHYSIOLOGY (2) : ARTERIAL OCCLUSION : THROMBOSISPROGRESSIVE ONSET WITH
ACUTE EXACERBATIONPAIN
PALLOR
PARESTHESIA
PARALYSIS
PULSELESSNESS
ELDERLY MALE > FEMALE
ATHEROSCLEROSIS
HT, DM, SMOKER, COPD
ATROPHIC CHANGE SKIN, HAIR, NAIL
BILAT EXT., EQUALLY INVOLVED
DIAGNOSIS HISTORY, PHYSICAL EXAM., DOPPLER, EKG
DOPPLER COLOUR ULTRASOND
MRI – ANGIOGRAM
CONVENTIONAL ANGIOGRAM
EMERG : MANAGEMENT : HEPARIN 80 UNITS/Kg I.V.BOLUS
MAINTENANCE 18 UNITS/Kg/HOUR
EARLY SURGICAL CONSULTATION : FOGARTY EMBOLECTOMY
SURGICAL BY PASS GRAFT, THROMBECTOMY
FOGARTY EMBOLECTOMY
MANIFESTATION BY PATHOLOGY
ARTERIAL OCCLUSION : TIA, STROKE
CAUSES BY EMBOLI – THROMBOSIS
ACUTE ONSET – TRANSIENT
RAPID PROGRESS
DEFINITE NEUROLOGICAL DEFICIT
UNDERLYING – ELDERLY, HT, DM
CT SCAN, HEPARIN, ANTIPLATELET
THORACIC AORTIC DISSECTION AND
ANEURYSM
TRAUMATIC RUPTURED OF THORACIC
AND IT BRANCHES
THORACIC AORTIC DISSECTION – MORTALITY 1%/HR.
MEDIAL NECROSIS OF AORTA, BICUSPID AORTIC VALVE
IN USA INCIDENCE 1-5 PER 100,000, TYPE A>B
44% OF MARFAN SYNDROME, POST CARDIAC SURGERY 14%
COMMON ASSOCIATE SYMPTOM : HYPERTENSION, SMOKER
CHEST PAIN 73% WIDENING MED 62%
AI MURMUR 40% LV HYPERTROPHY 25%
NORMAL CXR 15% NORMAL EKG 30%
SYMPTOMS & SIGNS- MIDLINE SUBSTERNAL CHEST
PAIN
- PULSE DEFICIT OR UNEQUAL
- ELDERLY MAN HYPERTENSIVE
- INVOLVED THORACIC ANEURYSM IN 30%
- NO ANEURYSMAL DILATATION IN 70%
- SOME PATIENT HAS NEUROLOGICAL DEFICIT
“ACUTE SPINAL CORD SYNDROME”
DIFFERENTIAL DIAGNOSIS – INVESTIGATION
ACUTE MYOCARDIAL INFARCTION – EKG, TROP-T
RUPTURE THORACIC AORTIC ANEURYSM, PE.
POST PERICARDIOTOMY SYNDROME – PERICARDITIS
BOERHAAVE’S SYNDROME : DYSPHAGIA, HEMATEMESIS
INVESTIGATION : CXR, EKG, ECHO, TEE, CT, MRI
EMERGENCY MANAGEMENT
REDUCE B.P. TO 100 – 120 mmHg
PR. TO 60 - 80
Morphine, BETA BLOCKER, NIROPRUSSIDE
EARLY CONSULTATION CARDIOLOGIST
SURGEON
MORTALITY SURGERY 20%MEDICAL Rx. 56%
OVERALL MORTILY IN HOSPITAL 30 – 40%
VASCULAR EMERGENCY – THORACIC AORTIC & BRANCH
BLUNT CHEST TRAUMA – SIDE, FRONT IMPACTED
USUAL ASSOC WITH FRACTURE UPPER RIB, STERNUM
SCAPULA, SHOULDER, CLAVICLE
STEARING WHEEL IMPRINT, FLAIL CHEST
MASSIVE HEMOTHORAX > 1500 cc, HYPOTENSIVE
UNEQUAL BLOOD PRESSURE AND PULSE OF ARM
MORTALITY AT THE SCENE > 30% (TRANSPORTATION)
MEDIASTINAL CLUES FOR GREAT VV. INJURY
OBLITERATION OF AORTIC KNOB
WIDENING OF MEDIASTINUM > 8 cm.
DEPRESSION OF LEFT MAIN BRONCHUS > 140°
LOSS PERIVERTEBRAL PLEURAL STRIPE
DEVIATION OF NASOGASTRIC TUBE
INVESTIGATIONS
CXR, PA – LAT. OBLIQUE, ECHOCARDIO. R/O CARDIAC INJ
CT, MRI, DSI (DIGITAL SUBSTRACTION ANGIOGRAM)
AORTOGRAM
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
RUPTURE ANEURYSM – SUBCLAVIAN
ACUTE NECK PAIN WITH OR WITHOUT STROKE
HOARSENESS, NECK SWELLING
AIR WAY OBSTRUCTION, EMBOLISATION
DEVIATION OF TRACHEA
ACUTE SVC OBSTRUCTION
DYSPHAGIA
RARE ONLY 1% OF PERIPHERAL ANEURYSM
RUPTURED AAAAAA – DILATATION OF AORTA > 50% OF DIAMETER
PREVALENCE 3 – 10% OF PATIENTS AGE OVER 50
PREVALENCE INCREASED BY : FAM HX, ELDERLY, MALE, SMOKING
ROUTINE PHYSICAL EXAM : LOW SENSIVITY 29% (3 – 4 cm)
50% (4 – 5 cm) 76% (>5 cm)
MOST ASYMPTOMATIC ARE DETECTED INCIDENTALLY DURING USG
FACTORS INCREASED RISK OF RUPTURE : HYPERTENSION
SMOKING, COPD, FAMILY HISTORY
DIAGNOSIS OF RUPTURED AAA50% OF PT. ARE UNAWARE OF AAA
PRESENT BEFORE
SUDDEN ONSET OF ABDOMINAL OR BACK PAIN – HYPOTENSIVE
TRANSIENT LOSS OF CONSCIOUS, ABDOMINAL MASS
ULTRASONND FOR UNSTABLE OR R/O AAA
CT FOR STABLE PATIENT
RETROPERITONEAL RUPTURE 80% FREE PERITONEAL 20%
MORTALITY FOR RUPTURED AAA 30 – 80%
PROBLEMS OF SUPTURED AAA IN ERDIAGNOSIS : KNOWN AND
UNKNOWN AAA
RESUSCITATION : KEEP B.P. 90 – 100 mmHg
IF BP < 80 DO NOT DELAYED IN ER
PATIENT GO DIRECTLY TO OR RESUSCITATION
ABDOMINAL PAIN – TENDER ANEURYSM OR
ELDERLY – HYPERTENSIVE – ABD PAIN + MASS OR
OTHER INTRA-
ABDOMINAL
ANEURIYSM
PERIPHERAL ARTERIAL ANEURYSM
FEMORAL
POPLITEAL
MESENTERIC OCCLUSION