Cardiothoracic and Vascular Surgery

Match each postoperative clinical presentation following cardiothoracic or vascular surgery with its corresponding pathophysiological mechanism or definitive diagnosis.

A 72-year-old man is brought to the emergency department by ambulance after losing consciousness at home. His wife reports that he had a brief episode of vomiting bright red blood earlier in the morning, which stopped spontaneously. However, just before the ambulance arrived, he experienced a massive episode of hematemesis and collapsed. His medical history is significant for hypertension, hyperlipidemia, tobacco use, and an open infrarenal abdominal aortic aneurysm repair four years ago. On arrival, he is diaphoretic and pale. His temperature is 37.1°C (98.8°F), blood pressure is 75/40 mmHg, pulse is 132/min, and respirations are 22/min. The abdomen is soft, non-tender, and mildly distended. Peripheral pulses are weak but symmetric. Two large-bore intravenous lines are placed and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing a distinct peripheral vascular presentation to its most appropriate anatomic diagnosis or pathophysiologic syndrome.

A 68-year-old man is brought to the emergency department by his neighbor after collapsing in his driveway. The patient is awake but lethargic, complaining of agonizing, tearing pain in his left flank that radiates to his groin. His medical history includes hypertension, severe chronic obstructive pulmonary disease (COPD), and atrial fibrillation. He states he ran out of all his medications two weeks ago.

Vital signs are temperature 36.8°C (98.2°F), blood pressure 76/48 mmHg, heart rate 134/min and irregularly irregular, respiratory rate 28/min, and oxygen saturation 92% on room air.

Physical examination reveals a pale, diaphoretic patient who is oriented only to person. Pulmonary auscultation reveals diffuse expiratory wheezes. The abdomen is distended, firm, and diffusely tender with absent bowel sounds. Deep palpation reveals a prominent pulsatile mass in the periumbilical region. A bedside ultrasound demonstrates a 7.2-cm infrarenal aortic aneurysm with a surrounding hypoechoic collection in the retroperitoneum.

Which of the following is the most appropriate next step in management?

A surgical clerkship student is reviewing the classic presentations of cardiovascular and thoracic disorders. For each clinical scenario described below, select the most accurate diagnosis.

A 68-year-old woman with a history of permanent atrial fibrillation and hypertension presents to the emergency department with a 3-hour history of sudden-onset, severe right leg pain. She admits to running out of her oral anticoagulant medication a week ago. On physical examination, the right foot and distal calf are pale and cool to the touch. Sensation to light touch is intact, and she can move all her toes without difficulty. Capillary refill is delayed. Palpation reveals a normal femoral pulse, but popliteal and pedal pulses are absent.

Arrange the following steps in the most appropriate sequential order for the evidence-based management of this patient's condition.

A 72-year-old man is brought to the emergency department after experiencing a sudden onset of severe, tearing pain in his lower back and left flank. His wife states that he briefly lost consciousness at home. His medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 45-pack-year smoking history. He does not take any anticoagulant medications. On arrival, he is lethargic, pale, and diaphoretic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 75/40 mmHg, heart rate 128/min, and respiratory rate 24/min. Physical examination reveals cold extremities with weak distal pulses. Abdominal examination demonstrates a tender, pulsatile mass in the periumbilical region. A bedside ultrasound confirms the presence of an infrarenal abdominal aortic dilation measuring 7.2 cm with an adjacent retroperitoneal hypoechoic fluid collection. Which of the following is the most appropriate next step in management?

Match each acute cardiothoracic or vascular surgical presentation with the most appropriate immediate next step in management.

An emergency medical services team brings a $68$-year-old male to the trauma bay following an episode of syncope at home. His wife reports that he complained of sudden, excruciating pain in his left flank and lower abdomen just before collapsing. His past medical history is significant for chronic obstructive pulmonary disease, hypertension, and a $45$-pack-year smoking habit. On arrival, he is lethargic, pale, and diaphoretic. Vital signs include a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure of $72/45\text{ mm Hg}$, heart rate of $128/\text{min}$, and respiratory rate of $26/\text{min}$. Palpation of the abdomen reveals significant distention and a tender, pulsatile mass just above the umbilicus. A point-of-care ultrasound performed immediately demonstrates a $6.8\text{ cm}$ infrarenal aortic dilation with surrounding retroperitoneal free fluid. Which of the following is the most appropriate next step in management?

Match each postoperative clinical presentation to the anatomical structure most likely injured during the cardiothoracic procedure.

A $58$-year-old man is brought to the emergency department by emergency medical services due to the sudden onset of severe, 'tearing' chest pain that radiates to his back between the scapulae. The pain started abruptly $45$ minutes ago while he was doing yard work. He has a history of poorly controlled essential hypertension. On arrival, he is diaphoretic and appears in acute distress. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $195/110$ mmHg in the right arm and $180/105$ mmHg in the left arm, heart rate is $108$/min, and respiratory rate is $22$/min. Oxygen saturation is $96\%$ on room air. A bedside chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological order for this patient.

Below are four distinct clinical scenarios involving peripheral vascular compromise. Pair each patient presentation with its most characteristic diagnostic finding.

A 58-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, tearing chest pain that radiates to his back. His blood pressure is 210/115 mmHg in the right arm and 170/90 mmHg in the left arm. His pulse is 112/min. Physical examination reveals a new diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes, and a chest x-ray reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 27-year-old man is brought to the emergency department by paramedics after sustaining a single stab wound to the left anterior chest during a physical altercation. On arrival, he is restless, diaphoretic, and confused. His temperature is 36.6°C (97.9°F), blood pressure is 64/38 mmHg, pulse is 142/min, and respiratory rate is 28/min. Oxygen saturation is 93% on a non-rebreather mask. Physical examination reveals a 3-cm laceration at the left fourth intercostal space, directly adjacent to the sternal border. His jugular veins are markedly distended. Pulmonary auscultation reveals clear and symmetric breath sounds bilaterally. Cardiac auscultation demonstrates faint and muffled heart sounds. The trachea is midline. A bedside focused assessment with sonography for trauma (FAST) confirms a large anechoic space surrounding the heart with evidence of right ventricular collapse during diastole. Rapid intravenous infusion of 1 liter of warmed crystalloid solution does not improve his blood pressure. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old man is brought to the emergency department by paramedics following a street altercation where he sustained a stab wound to his left anteromedial thigh. On presentation, he appears pale, diaphoretic, and confused. His temperature is 36.5°C (97.7°F), blood pressure is 82/46 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Physical examination reveals a 4-cm laceration over the left medial thigh. There is a rapidly expanding hematoma around the wound and active pulsatile bleeding. The left foot is cold to the touch. Capillary refill is delayed in the left toes, and both the left dorsalis pedis and posterior tibial pulses are absent to palpation and Doppler ultrasound. The right lower extremity has normal pulses. Which of the following is the most appropriate next step in the management of this patient?

Match each traumatic clinical presentation and its associated physical exam findings to the most likely specific vascular injury.

A 27-year-old male is transported to the trauma bay after sustaining a knife wound to his right thigh during an altercation. On initial assessment, the patient is diaphoretic and confused. Vital signs show a heart rate of 134/min and a blood pressure of 80/42 mmHg. Examination of the right lower extremity reveals a 4-cm laceration over the anteromedial thigh with a rapidly expanding, pulsatile swelling beneath the skin. The right foot is markedly pale compared to the left, and no pulses are audible on Doppler ultrasound over the right dorsalis pedis or posterior tibial arteries. Intravenous access is established and rapid crystalloid infusion is started. Which of the following is the most appropriate next step in management?

During the overnight shift in the intensive care unit, a nurse urgently pages the surgical resident to evaluate a patient admitted earlier that evening. The patient, a 59-year-old male with a history of poorly controlled essential hypertension, was recently diagnosed with an acute descending thoracic aortic dissection. Initial management with an esmolol infusion successfully reduced his blood pressure to 112/74 mmHg and heart rate to 62/min.

Upon arrival at the bedside, the resident finds the patient writhing in agony, complaining of severe, diffuse abdominal pain that began abruptly 30 minutes ago. Physical examination reveals a soft, non-distended abdomen with vague, mild tenderness to deep palpation and absent peritoneal signs. Bowel sounds are hypoactive. The lower extremities are warm with symmetric, easily palpable pedal pulses. Laboratory studies drawn stat reveal a serum lactate level of 6.3 mmol/L and a leukocyte count of 18,500/mm³.

Which of the following is the most appropriate next step in management?

Match the following specific clinical presentations and physical exam findings with their most likely cardiothoracic or vascular surgical diagnosis.

A 68-year-old man with a history of poorly controlled hypertension is brought to the emergency department due to sudden-onset, severe, tearing interscapular back pain. On arrival, his blood pressure is 215/115 mmHg, and his heart rate is 118/min. He appears diaphoretic and in severe distress. An electrocardiogram shows sinus tachycardia with no ischemic changes. A portable chest radiograph demonstrates a widened mediastinum. The physician strongly suspects an acute aortic dissection. Arrange the following evaluation and management steps in the most appropriate chronological sequence for this patient.