Abdominal Vascular Emergencies: Pearls and PitfallsBrian Lin, MD, FACEPKaiser Permanente, San Francisco Emergency DeptClinical Assistant Professor, UCSFHigh Risk Emergency Medicine Hawaii 2014 No financial disclosures or relationships. • 66 yo M hx of previous kidney stones and known AAA (measured at 5.4 cm by US one month ago)• Today developed very severe pain in R flank, no abd pain, sudden onset; does feel like previous renal stone• Background of vague back pain for 2-3 weeks Clinical Case:“Peter” • Patient concerned about radiation risks• Urine dipstick: large blood• Creatinine (baseline): 2.3 His previous CT Angio Clinical Case:“Peter” AAA
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Abdominal Vascular Emergencies:
Pearls and Pitfalls
Brian Lin, MD, FACEPKaiser Permanente, San Francisco Emergency Dept
Clinical Assistant Professor, UCSFHigh Risk Emergency Medicine Hawaii 2014
No financial disclosures or relationships.
• 66 yo M hx of previous kidney stones and known AAA (measured at 5.4 cm by US one month ago)
• Today developed very severe pain in R flank, no abd pain, sudden onset; does feel like previous renal stone
• Background of vague back pain for 2-3 weeks
Clinical Case:“Peter”
• Patient concerned about radiation risks
• Urine dipstick: large blood
• Creatinine (baseline): 2.3
His previous CT Angio
Clinical Case:“Peter”
AAA
Abdominal Vascular Emergencies
Abdominal AorticAneurysm (AAA)
Aortic Dissection (AD)
Acute Mesenteric Ischemia (AMI)
Detection(When/How
to Test)
Diagnosis(Imaging)
Decision(ED Treatment& Consults)
~60 yrs +Concerning hx Pulsatile mass
CT angio OR
US, CT(-) with clinical picture
Volume +(Vasc) Surg
orDie
Good Hx, “Weird” Exam
Consider Ddimer, US
(1) CTA(2) TEEU/S: take a
look...
Lower BP!A: Surgery
B, complicated: (Vasc) Surgery
B: Medicine
Abd pain+elderly
+embolic risk+/- lactate
CTA
Volume, abx, heparin gtt;
IR +(Vasc) Surgery
Dx
Strategy
AAA
AD
AMI
Goals & Objectives
• History & Physical
• Serum Biomarkers
• Diagnostic Imaging
AAA
AD
AMI
Pearls and Pitfalls related to:
History & Physical
History
• Sudden onset epigastric pain
• Flank pain or back pain
• Syncope
AAA
Contained Rupture
AAA
• Flank pain or back pain
• Sensitivity: 76%
• PPV: 43%
• Positive Likelihood ratio: 15.6 [CI 8.6-15.6]
Physical Exam:Abdominal Palpation
JAMA 1999
AAA
Take Home Point #1
Abdominal vascular emergencies don’t always present within the abdomen.
Considering AAA?Look at the legs!AAA
Pitfall:
You have to look!Symptom/Finding Increased Disease