Triple AAA

[Paraone]

just over the past weekend we were doing scenarios in class and one scenario we talked about a little and actually tried to to diagnose in a practice scenario was, when a patient was experiencing a Triple AAA. what kind of symptoms is this patient going to have, that is going to indicate a triple AAA? Also what signs should I be looking for that is going to indicate I should take a BP on both arms? I was little confused with this scenario!!

[dentedhead]

just over the past weekend we were doing scenarios in class and one scenario we talked about a little and actually tried to to diagnose in a practice scenario was, when a patient was experiencing a Triple AAA. what kind of symptoms is this patient going to have, that is going to indicate a triple AAA? Also what signs should I be looking for that is going to indicate I should take a BP on both arms? I was little confused with this scenario!!

A triple A, or ascending aortic anuerism is typically manifested by chest/abdo pain radiating either between the shoulders or into the groin dependant on where the tear is.The pain will be described as either sharp or it feels like something is tearing.This is typical not necessarily in all cases,either some all or more symptons may be present.

Yes take a BP in both arms ther should be a deficit,usually left is higher than right.This should be monitored Q5 as it can start bottoming quick.

Pt may present mild to severly short of breath with appropriate skin coloration IE pale to cyanosed.If available O2 saturation is a good indicator of perfusion.

Physical findings may be:

H/N-usually nothing obvious in the acute phase these dont go much past acute.If its a slow leak the jugs may be flat.

Chest-Should be bilateral A/E may be decreased breath sounds due to the aortic bulging.....again dependant on where the tear is.

Abdo-Should be soft with tenderness and guarding,strong possibility of a palpable mass or a pulsatile mass on observation.

EXT-Decreased blood flow to lower ext,cool to touch,dusky appearance and hard to palpte distal pulse slow to no cap refill.

Oh these hard medical questions make me think about a time in my life I want to forget:eek: .

Dentedhead
P.S hope that helps

[Paraone]

Hey Dentedhead..Thanks for the reply. Out of those signs and symptoms, which would be the best indicator to be checking the BP on both arms? I was thinking when the pt. describes the chest pain as "sharp shooting pain radiating to the back right scalpula"?

One other question for you. Why would the left BP usually be hire than the right? Would this patient present with pulmonary edema?
I tried to figure this one out on my own before I asked but what does H/N stand for and why would the Jugular veins be flat if the aorta had a slow leak?

Sorry for all the questions, I am just trying to understand how a pt. would be presenting.

p.s. please one more question? when you initiate an Iv N/S and the BP is below 90 would you bolus this patient or would you run it at maintenance rate?

Trauma calls are sooo much easier

[dentedhead]

Hey Dentedhead..Thanks for the reply. Out of those signs and symptoms, which would be the best indicator to be checking the BP on both arms? I was thinking when the pt. describes the chest pain as "sharp shooting pain radiating to the back right scalpula"?

One other question for you. Why would the left BP usually be hire than the right? Would this patient present with pulmonary edema?
I tried to figure this one out on my own before I asked but what does H/N stand for and why would the Jugular veins be flat if the aorta had a slow leak?

Sorry for all the questions, I am just trying to understand how a pt. would be presenting.

p.s. please one more question? when you initiate an Iv N/S and the BP is below 90 would you bolus this patient or would you run it at maintenance rate?

Trauma calls are sooo much easier

Now I am going to have to think.I know why dont you go look it up and then tell me.....I guess that only works if you are teacher or parentLOL.

H/N is short for head and neck.Jugs will be flat(ter) due to decreased blood flow from the leak.The carotid pulse will most likely be weak.

As I said before there really is no hard and fast rule for pt presentation,I just outlined the common ones.If you feel that it could be an AA treat it as such.I was taught paramedicine on the horrendo principle.Start at the worst and work backwards.Just dont get tunnel vision,look at the whole pt.

The BP on the left will be higher due to the fact the heart dosent have to work as hard to push the blood to the closer arm,the right arm is fiurther to go.The difference could be very obvious or neglible.Again an asessment tool not a hard and fast Dx.There may or may not be any PE again dependant on pt Hx age condition etc.

If I remember correctly that an N/S IV in an event such as this is really only a port,bolusing or pressure bags can be risky due to the impending anuerism bursting.Its been a while since I have stuck anyone so yor on your own to find that answer for certain.Prehospital Tx is also way different than what you may see in the clinical setting.

Dentedhead

[Paraone]

Thanks for the info. I guess it comes down to treat the signs and symptoms and take them to the big green H! I must say, I never knew becoming a paramedic would be so interesting. You know you take your OFA or your EMR thinking there is nothing to this job. You perform a little CPR, give some nitro, and put a band aid on a wound and there all better! LOL, well that is so wrong! As I am learning in school, there are so many reasons to why a person has requested an ambulance. COPD,Angina,abd pain, or they are just not feeling well. I cant wait to learn more and be able to pass what I have learned down to juinor paramedics one day!

Thanks again for your help Dentahead!

[dentedhead]

Thanks for the info. I guess it comes down to treat the signs and symptoms and take them to the big green H! I must say, I never knew becoming a paramedic would be so interesting. You know you take your OFA or your EMR thinking there is nothing to this job. You perform a little CPR, give some nitro, and put a band aid on a wound and there all better! LOL, well that is so wrong! As I am learning in school, there are so many reasons to why a person has requested an ambulance. COPD,Angina,abd pain, or they are just not feeling well. I cant wait to learn more and be able to pass what I have learned down to juinor paramedics one day!

Thanks again for your help Dentahead!

No probs if I can help I will,just remember I am a few years removed from humping stretchers, that coupled with CRAFT syndrome I might not know what you need!!

Dentedhead

[Paraone]

Well any insight to any medical or trauma related question from you or anybody else is alway appreciated!

[MadMedic]

"Tearing" is a common description by many patients experiencing a disecting AAA. You many be able to hear pulsations when ausc. the abdomen or while ausc. lung fields. You many find a syst. difference >/= 30mmMg between arms. AAA's can be hard to detect in the field. A good PQRST /LOTAARPS can help keep you organized, if you are encountering an abnormal C/P presentation with no obvious other cause, AAA should be considered. The greatest asset in field for this condition often is just recognizing the possiblity that the cause of the pt's complaint may be from a AAA. This situation can only be managed by a surgeon and can rapidly get out of hand so very delicate but rapid transport is required.

[deville]

Great post MadMedic. Not familiar with LOTAARPS. Im sure I could figure it out in time but its much easier to ask you. Thx.

[Paraone]

LOTAARPS

L-Location where is the discomfort? have you had this discomfort before? have you been to the hospital for this discomfort? If yes, what did the Dr. say?

O-Onset, when did the discomfort start? Has it been there the entire time or has does it come and go?

T-Type, can you discribe the discomfort? Ask is it the same discomfort as you have experienced in the past? Can you rate the discomfort out of ten?

A- Associated symptoms? I ask the patient if they have SOB,dizzyness,sweating,nauseated?

A-Aggravating symptoms? what makes the discomfort worse? I actually ask the patient to take a deep breath and see if that changes anything. I also move the patients arms to see if that changes the discomfort in the chest. I rock the patient forward to see if that changes the discomfort. I also poke at the intercostal muscles to see if that changes any of the discomfort. If the patient says when I move the arms or poke at the intercostal muscles, it makes me think that the discomfort has to do with a muscleskeletal injury.

R-Relieving factors, I ask the patient if they have done anything to make the discomfort better. Any medications? If so how did it change the discomort? 0/10

P-Percipitating events, what was the patient doing when the discomfort came on?

Now the "S'' I am not hundred percent sure of what the "S" is used for? I am going to guess that the "S" stands for "Signs" is the patient in "Shock", low blood pressure, dizzy, But as stated, I am not 100% sure.

MadMedic could probably answer that for us please.
My preceptor taught me this way of questioning a patient with any complaint it works great!! I know in my PCP class we were taught the LOTARP, but I did not fully understand it until I acutally used it in the field.

[dentedhead]

Another reason i got out of ems...cant even stick with simple neumonics.
Whatever happened to......

O-nset
P-rovocation/palliation
Q-uality
R-adiation
S-everity
T-ime

Or

A-lcohol/acidosis
E-pilepsy
I-nsulin
O-verdose
U-remia
T-rauma/tumour(decreased LOA,behaviour)
I-nfection
P-sychiatric
S-troke

Dentedhead

[firechick15]

OPQRST and AEIOUTIPS are both still used. LOTARP is just a variation of OPQRST. Some paramedics prefer LOTARP but to most of us it doesn't make much difference. Maybe it is a BC thing. It is whatever it takes to get the answers to the questions you need for your history.

[FiremanLGT]

Gee Whiz...that Dentedhead is a real prick just like so many of youz guys say. He never ever offers any relavant help or advice ever. Gosh!!!!! Why do I even log on to this site.

;)

[MadMedic]

"S" is Severity out of ten or Mild, Moderate, Severe, etc. also associated symptoms can fall under 'S' as well.

[MadMedic]

OPQRST and AEIOUTIPS are both still used. LOTARP is just a variation of OPQRST. Some paramedics prefer LOTARP but to most of us it doesn't make much difference. Maybe it is a BC thing. It is whatever it takes to get the answers to the questions you need for your history.

lol yes they're still used, as well as a TON of other ones. Pick a subject, we prob. have a nuemonic for it.

[dentedhead]

lol yes they're still used, as well as a TON of other ones. Pick a subject, we prob. have a nuemonic for it.


Every specialty in medicine has more than we will ever learn.My wife who is an RN has also taught me bunch,they have no use in EMs but are good to help decipher nursing notes.


My favourite has to be the 5F's.....no not that one you perverts!!

Dentedhead

[iekvek]

The BP on the left will be higher due to the fact the heart dosent have to work as hard to push the blood to the closer arm,the right arm is fiurther to go.The difference could be very obvious or neglible.Again an asessment tool not a hard and fast Dx.There may or may not be any PE again dependant on pt Hx age condition etc.


This is actually proving to be a myth in recent literature as the true difference in distance is negligable, perhaps a couple of cm at best. It has been a bit of an adjustment for me to keep it in mind though.



If I remember correctly that an N/S IV in an event such as this is really only a port,bolusing or pressure bags can be risky due to the impending anuerism bursting.Its been a while since I have stuck anyone so yor on your own to find that answer for certain.Prehospital Tx is also way different than what you may see in the clinical setting.


A good point, the goal should be to try to maintain a BP significant enought to maintain a decent cerebral perfusion pressure (CPP). In most patients, this would be in the 70-80 systolic range. The modality is referred to as permissive hypotension. The reasoning is that by increasing the SBP, you can help them bleed out quicker and you effect intrinsic clotting factors.

[dentedhead]

This is actually proving to be a myth in recent literature as the true difference in distance is negligable, perhaps a couple of cm at best. It has been a bit of an adjustment for me to keep it in mind though.




A good point, the goal should be to try to maintain a BP significant enought to maintain a decent cerebral perfusion pressure (CPP). In most patients, this would be in the 70-80 systolic range. The modality is referred to as permissive hypotension. The reasoning is that by increasing the SBP, you can help them bleed out quicker and you effect intrinsic clotting factors.

Well there you go I learned sumpin new today.I was taught the distance thing. If you look at an anatomical drawring it is also very plausible for either arguement.

There is far more at play than what we have discused thats for sure...oh man what next cardiac output? stroke volume? LOL.Oh I know wedge pressures :D.It is actually nice to think about and discuss this stuff occaisionally....and I do mean occaisionally!

Thats why I am just happy to sit backwards and not think for myself as my best friend who is still a medic likes to say.

Dentedhead

[Pumper99]

A triple A, or ascending aortic anuerism is typically manifested by chest/abdo pain radiating either between the shoulders or into the groin dependant on where the tear is.The pain will be described as either sharp or it feels like something is tearing.This is typical not necessarily in all cases,either some all or more symptons may be present.

Yes take a BP in both arms ther should be a deficit,usually left is higher than right.This should be monitored Q5 as it can start bottoming quick.

Pt may present mild to severly short of breath with appropriate skin coloration IE pale to cyanosed.If available O2 saturation is a good indicator of perfusion.

Physical findings may be:

H/N-usually nothing obvious in the acute phase these dont go much past acute.If its a slow leak the jugs may be flat.

Chest-Should be bilateral A/E may be decreased breath sounds due to the aortic bulging.....again dependant on where the tear is.

Abdo-Should be soft with tenderness and guarding,strong possibility of a palpable mass or a pulsatile mass on observation.

EXT-Decreased blood flow to lower ext,cool to touch,dusky appearance and hard to palpte distal pulse slow to no cap refill.

Oh these hard medical questions make me think about a time in my life I want to forget:eek: .

Dentedhead
P.S hope that helps

this is excellent. We're running into this more and more. Thanks DH.

P99