emq: VASCULAR EMERGENCIES
Match each clinical vignette to the most appropriate diagnosis.
Carotid artery dissection Uncomplicated pseudoaneurysm Deep vein thrombosis of the lower limb Stanford B dissection of the aorta Vertebral artery dissection |
Chronic femoral artery insufficiency Stanford A dissection of the aorta Fracture of the radial head Supracondylar fracture Mycotic aneurysm DeBakey III dissection of the aorta |
EMQ 1.
A 55 year old man with a history of hypertension presents with acute neck pain and dizziness. On examination he has rotatory nystagmus.
Answer: vertebral artery dissection.
Comment: the combination of the clinical history with signs of a posterior circulation infarct suggest a complicated vertebral artery dissection.
EMQ 2.
A 68 year old man with a history of poorly controlled type 2 diabetes and two prior NSTEMIs presents complaining of increasing pain in his right leg. The pain occurs after walking more than 50m, and spreads upwards from his foot towards his groin.
Answer: chronic femoral artery insufficiency
Comment: this patient is describing vascular claudication, most likely due to severe atherosclerosis. He will probably be a candidate for femoral-popliteal bypass surgery.
EMQ 3.
A 62 year old man presents with sharp central chest pain of a tearing nature radiating through to his back. His systolic blood pressure on arrival is 210mmHg, and his ECG in the resus room shows 3mm of ST elevation in leads II, III and aVF.
Answer: Stanford A dissection of the aorta.
Comment: Stanford A dissections involve the ascending aorta, most commonly the right wall, and may dissect off the right coronary artery, causing a STEMI.
EMQ 4.
A 5 year old boy presents with a swollen left elbow after falling off the monkey bars at day care. His left elbow is quite swollen and his left hand is cool and pale. On palpation a radial pulse cannot be felt.
Answer: supracondylar fracture of the humerus.
Comment: 5-20% of supracondylar fractures (usually higher grades) are complicated by vascular injury
EMQ 5.
A 24 year old drug user presents with a fever and right groin pain. There is a large indurated tender mass in the right groin on examination.
Answer: mycotic aneurysm
Comment: infected pseudoaneurysms occur in the common or superficial femoral artery of injecting drug users. The presence of systemic signs of infection argues that this is a mycotic (infected) pseudoaneurysm, rather than an uncomplicated pseudoaneurysm.
A 55 year old man with a history of hypertension presents with acute neck pain and dizziness. On examination he has rotatory nystagmus.
Answer: vertebral artery dissection.
Comment: the combination of the clinical history with signs of a posterior circulation infarct suggest a complicated vertebral artery dissection.
EMQ 2.
A 68 year old man with a history of poorly controlled type 2 diabetes and two prior NSTEMIs presents complaining of increasing pain in his right leg. The pain occurs after walking more than 50m, and spreads upwards from his foot towards his groin.
Answer: chronic femoral artery insufficiency
Comment: this patient is describing vascular claudication, most likely due to severe atherosclerosis. He will probably be a candidate for femoral-popliteal bypass surgery.
EMQ 3.
A 62 year old man presents with sharp central chest pain of a tearing nature radiating through to his back. His systolic blood pressure on arrival is 210mmHg, and his ECG in the resus room shows 3mm of ST elevation in leads II, III and aVF.
Answer: Stanford A dissection of the aorta.
Comment: Stanford A dissections involve the ascending aorta, most commonly the right wall, and may dissect off the right coronary artery, causing a STEMI.
EMQ 4.
A 5 year old boy presents with a swollen left elbow after falling off the monkey bars at day care. His left elbow is quite swollen and his left hand is cool and pale. On palpation a radial pulse cannot be felt.
Answer: supracondylar fracture of the humerus.
Comment: 5-20% of supracondylar fractures (usually higher grades) are complicated by vascular injury
EMQ 5.
A 24 year old drug user presents with a fever and right groin pain. There is a large indurated tender mass in the right groin on examination.
Answer: mycotic aneurysm
Comment: infected pseudoaneurysms occur in the common or superficial femoral artery of injecting drug users. The presence of systemic signs of infection argues that this is a mycotic (infected) pseudoaneurysm, rather than an uncomplicated pseudoaneurysm.