Please enable JavaScript.
Coggle requires JavaScript to display documents.
Acute limb ischemia (Clinical presentation (6P's) (Pain, Parasthesia,…
Acute limb ischemia
Clinical
presentation (
6P's)
Pain
Parasthesia
Paralysis
Perishingly cold
Pulseless
Pallor
Diagnosis
Examination
Peripheral vascular exam
Limb is pale, cold, absent pulses,
reduced sensation, reduced motor
Neuro exam
Sensation loss, weakness/paralysis
Cardio exam
AF, R-R/R-F delay if dissection
Investigations
Bedside
Obs (low BP and high HR if dissection/trauma)
ECG (arrhythmias)
ABPI - reduced; <0.5 is critical
Bloods
Group&save/crossmatch
ABG/VBG (lactate), FBC (anaemia makes ischemia worse),
CRP/ESR (CT disorder, U+E (RAS, rhabdomyolysis), LFTs, glucose, lipids, CK (rhabdomyolysis)
Imaging
CXR/AXR (aortic dissection, trauma)
USS aortic, femoral popliteal (blockages)
CT angio (site and extent of blockage pre-surgery;
inter-arterial digital subtraction DSA is gold standard)
ECHO (mural thrombi)
History
HPC
Sudden onset 6P's, recent trauma
PMH
Aneyrysms, PVD, previous surgeries,
other CVD disease
DH
Meds (antiplatelets, anticoagulants),
allergies
FH
CVD, PVD, aneurysms
SH
-
Living arrangements, occupation,
smoking, alcohol, diet, obesity
Tissue viability
Threatened
(salvageable if promptly treated)
CRT slow
No paralysis
Partial sensory loss
Inaudible arterial but audible venous Doppler
Threatened
(salvageable if immediately treated)
CRT>2s
Partial paralysis
Partial sensory loss
Inaudible arterial but audible venous Doppler
Viable
CRT<2s
No paralysis
No sensory loss
Audible arterial/venous Doppler
Irreversible
(Amputation needed)
Absent CRT
Complete paralysis
Complete sensory loss
Inaudible arterial/venous Doppler
Aetiology
Trauma
Limb trauma
Iatrogenic
Limb/graft occlusion
Vascular
Thrombus e.g. PVD
Embolus e.g. AF, mural thrombi, aneurysm
Dissection
Complications
Loss of limb
Reperfusion injury
Release of toxic compounds from necrotic cells
Haemodynamic instablility
Compartment syndrome
Reduced blood inflow and outflow
Increased intra-compartment pressure
Tissue ischemia and necrosis
Pathophysiology
Defect
Usually an embolus causing sudden blockage
e.g. AF, mural thrombi, arteral aneurysm, DVT (if patent FO)
Trauma e.g. limb trauma causing compression or compartment syndrome
Can also be due to thrombi, but less likely as this usually develops chronically over time with collaterals forming
Also dissection and graft dysfunction
Mechanism
Sudden blockage of an artery supplying the limb,
causing ischemia
If ischemia prolonged >4-6h, tissue necrosis can occur
I.e. it is an MI of the leg (NSTEMI)
Management
Initial ABCDE
Definitive
Medical
Anticoagulation
Indication: ASAP all patients
E.g. unfractionated heparin
MOA: prevents further coagulation; unfractionated
heparin has shorter half life than LMWH so good pre-surgery
SEs: haemorrhage, reperfusion injury
Analgesia
Indication: pain
E.g. morphine + antiemetic
Surgery
(<4-6h to save)
Surgical embolectomy
Indication: embolic cause
MOA: Foley catheter to remove embolus
SE: reperfusion injury, compartment syndrome
Percutaneous transluminal angioplasty
Indication: thormbotic cause
MOA: angioplasty +/- PCI
Amputation
Indication: irreversible ischemia, gangrene
MOA: try to preserve knee (function)
Conservative
Information, advice, support
Identify and treat cause
ASAP to vascular
Definition
Acute reduction in limb perfusion
causing new/worsening S+S,
threaten limb if not revascularised in 4-6h
VASCULAR EMERGENCY