Welcome to the 286 podcast. Uh this will be the last episode for the cardiac emergencies PowerPoint. Uh just covering aneurysms in this one. So an aneurysm is a localized sack uh or dilation formed at a weak point in the wall of an artery. Uh this could be because um a damaged media layer of the vessel has caused the aneurysm to form. They're classified by shape and form. So A is just a normal vessel. B is a false aneurysm. C is a true aneurysm. D fusifform. E sacular and F dissecting. Your most common types of aneurysms are going to be the sacular and fusive form. So your D and E. Aneurysms can potentially be serious and fatal if there's one located in a large vessel. If it ruptures, it's going to cause hemorrhaging and death. The goal is to prevent rupture and dissection. Uh we can perform surgery to fix it before it gets too big. But an aneurysm is like a ticking time bomb. As it gets larger and larger, it can eventually dissect and rupture. When an aneurysm is discovered, the patient will either get surgery to go in and fix it or stabilize it, or it will be monitored if it's not too big yet. Usually monitored with testing every 6 months to look to see if it's grown or not. The time frame can change for this though, depending on the size. Uh they're going to wait um until the size and risk of rupture is greater than the risk of complications from surgery. Usually if it's growing rapidly or if it's less than five and a half centimeters which is about two inches surgery will be performed. Some aneurysms will remain stable for years and will require no interventions. Some risk factors for this smoking, hyper lipidmia, men and a family history. Some causes can include congenital connective tissue disorders like Marfon syndrome where the patient is tall and thin with long arms, fingers, legs, toes. They have damaged connective tissue with this disorder. Turner syndrome where a female is born with only one X chromosome which causes heart defects primarily in the aorta. uh hypertension, trauma like um penetrating or blunt arterial injuries, infections caused by bacteria or fungi and atherosclerosis which is that plaque buildup um on the arterial walls. Your thoracic um aortic aneurysms are your most um your most common cause of these is going to be atherosclerosis. U most frequent in men ages 50 to 70. It affects 10 out of every 100,000 older adults. And I know that number doesn't seem very large to you, but it is a very common um complication. This is your most common area for dissection. So there's a high mortality rate here. So it's a big emergency. Your clinical manifestations pre- dissection. Uh most of your patients are going to be asymptomatic, but they could have dispa uh berdypnia. This is where the aneurysm is pressing on the trachea or the lungs. Have a brassy cough or horse voice. This is from pressure on the vocal cords. Uh dysphasia, chest, back, jaw, or neck discomfort. During dissection though, it's all of those above plus chest or back pain. This is going to feel like a tearing or sharp pain. pain in the jaw or neck, cyanosis, hypotension, tacocardia, and then there's going to be a 20 um millimeter per mercury, millimeters of mercury, systolic difference between the right and left arm. For diagnostics, we're going to get a chest X-ray. We can do a CT angog of the chest as well. That's a CT with contrast. For your abdominal, uh your most common cause here is also aosclerosis. It's going to affect men two to six times more often than women and it is more common in Caucasians. More prevalent in ages over 65. Uh without treatment here, these abdominal aneurysms will rupture and result in death. 60% of individuals are asymptomatic while 40% have symptoms. It may feel like they have a heartbeat in their abdomen or their abdomen is throbbing. You'll see a pulsatile mass. Signs of impending or active rupture. This could be severe low back pain, pressure on lumbar nerves or an abdominal pain um mid to lower abdomen. Hypotension, decreasing hematocrit. uh if it's rupturing into the paritinal cavity they could have increasing abdominal girth. If it's rupturing into the retroparitinal cavity you could see hematomas in the scrotum paraneium flanks or penis. For our diagnostics here the hallmark sign is a pulsatile mass in the middle upper abdomen. It's more difficult to feel or even uh see in uh patients who are overweight or obese. So this could be missed. Uh if you were to listen over the um aorta in the abdomen, you would hear a brewy over the mass, which is the sound of blood flow through a narrowed artery. Again, think atherosclerosis as your main cause here. Blood pressure may be lower in the legs than the arms. Um and your CT scans and ultrasound can help determine the size, length, and location of the aneurysm as well. for our nursing considerations here. Uh we're not going to palpate the abdomen if one of those pulsatile masses is present. We do not want to rupture it. We want to frequently monitor the patient's blood pressure. We're going to get a CBC and we want to instruct our patient to avoid bending, lifting, or constipation. So how do we treat aortic aneurysms? Well, blood pressure control is the first thing that we want to get um under control. While an aneurysm is just being monitored, patients have to control their blood pressure at home to slow the growth and prevent dissection. When it is dissecting though, this is an emergency and we need emerent blood pressure control with beta blockers, hydraysene, nitropide can be given as an IV drip in emergency situations like your dissection. It this can be titrated and it does have a short uh duration. We want to maintain a systolic pressure between 90 to 100 millm of uh sorry 90 to 120 millm of mercury uh and a map between 65 and 75. Uh if you have um this nitropide drip, we do need to make sure that we have titratable orders. We also want to try to keep the patient calm and reduce anxiety, reducing their cardiac work and output. We're going to put them on bed rest. We're going to give them oxygen and if they do have a rupture, we're going to need a blood transfusion and emergency surgery. For resecting and grafting, the main treatment is resection. Uh we basically take portions of the damaged artery and insert a graft like you see on the right hand side there. Essentially, what it's doing is it's redirecting blood flow away from the bulging artery. Instead, um it flows through the graft instead of the main artery. For posttop care for this the most common way to place the graft is um perccutaneously through an artery very similar to um cardiac calath. We can place this through uh brachial artery or femoral artery. The patient's going to remain supine for at least 6 hours. We can help uh elevate the head of the bed 45 degrees after the first two hours though. no bending of the leg that they um went through the groin uh side of the groin that they went through. Uh that leg must remain straight. They're going to use a bed pan or urinal while they're on bed rest. We're going to get vital signs and Doppler assessment of peripheral pulses initially every 15 minutes and then less and less as your patient recovers. Um again, follow facility protocol per usual. We're also going to do frequent assessment of the insertion site. We want to check for any bleeding or hematomas. Things that we would report to the provider include bleeding, swelling, pain, hematomas, changes in vital signs, cyanosis, a systolic blood pressure greater than 180 millm of mercury. If the patient has persistent coughing, sneezing, vomiting, all of these increase the risk for hemorrhaging. We also want to monitor their temperature every 4 hours post-operatively. Um you could see what's called post manipulation syndrome uh where you'll see fever, luccoytosis and we treat this with antipyetics. Your patient can resume a normal diet. We want to encourage them to drink a lot of fluid and we want to frequently monitor their renal function. Kidney uh injury is really common especially with that contrast dye. Uh so we want to make sure that we are getting those buin and creatinin as well. And that is going to be all for aneurysms.