VASCULAR
ISCHAEMIC LIMB
PromptCauses of limb ischaemia
ResponseThrombotic - atherosclerotic plaque
Embolic - AF/CCF/AAA
Traumatic - penetrating injury
Iatrogenic - IVC or IV drug aterial injection
Aortic dissection extending to affected limb/artery
Thoracic outlet syndrome
Embolic - AF/CCF/AAA
Traumatic - penetrating injury
Iatrogenic - IVC or IV drug aterial injection
Aortic dissection extending to affected limb/artery
Thoracic outlet syndrome
PromptHISTORY favouring embolic cause of ischaemia
ResponseMinimal history of atherosclerotic disease
No/minimal history of claudication
Acute/sudden onset of symptoms
History of pAF
History of valvular heart disease/prosthetic valve
Known AAA
Known endocarditis
Known LV aneurysm/cardiomyopathy
No/minimal history of claudication
Acute/sudden onset of symptoms
History of pAF
History of valvular heart disease/prosthetic valve
Known AAA
Known endocarditis
Known LV aneurysm/cardiomyopathy
PromptEXAMINATION favouring embolic cause ischaemia
ResponsePresence of AF
Clinical signs of bacterial endocarditis
Hear murmurs suggesting valvular heart disease
Presence of abdominal aortic, femoral or popliteal aneurysm
Degree of demarcation sharp rather than more diffuse in thrombotic disease
Absence of chronic ischaemic changes in limb (Eg: wasting, hair loss, skin atrophy, ulceration) - ie: Normal contralateral limb on examination
Good proximal and collateral pulses
Sit of demarcation at major bifurcation of arteries
More extensive gangrene or more obviously limb threatening
No collateral circulation on imaging
Clinical signs of bacterial endocarditis
Hear murmurs suggesting valvular heart disease
Presence of abdominal aortic, femoral or popliteal aneurysm
Degree of demarcation sharp rather than more diffuse in thrombotic disease
Absence of chronic ischaemic changes in limb (Eg: wasting, hair loss, skin atrophy, ulceration) - ie: Normal contralateral limb on examination
Good proximal and collateral pulses
Sit of demarcation at major bifurcation of arteries
More extensive gangrene or more obviously limb threatening
No collateral circulation on imaging
PromptClinical features favouring thrombotic cause of ischaemia
ResponseHistory of claudication
History of PVD
Gradual onset of symptoms
Signs of arterial disease bialterally (Shiny skin, hyperpigmentaiton, hair loss, ulcers)
Widespread disease with collateral circulation on imaging.
History of PVD
Gradual onset of symptoms
Signs of arterial disease bialterally (Shiny skin, hyperpigmentaiton, hair loss, ulcers)
Widespread disease with collateral circulation on imaging.
PromptSociety for vascular surgery classification of lower limb ischaemia vs clinical findings
Response
PromptInvestigations in limb ischaemia
ResponseBedside:
ABI (<0.5)
No pulses on doppler US
Formal:
FBC - polycythemia/risk of thrombus
ECG - AF as risk factor for embolism
Doppler - Pulse presence or absence and quantify flow
US upper arm - thrombus or embolism
CXR - Cervical ribs for thoracic outlet obstruction
CT neck/thorax - Thoracic outlet1
ABI (<0.5)
No pulses on doppler US
Formal:
FBC - polycythemia/risk of thrombus
ECG - AF as risk factor for embolism
Doppler - Pulse presence or absence and quantify flow
US upper arm - thrombus or embolism
CXR - Cervical ribs for thoracic outlet obstruction
CT neck/thorax - Thoracic outlet1
PromptDescribe ED management of embolic ischaemic limb
ResponseMedical
Retrieval to subspecialty service
- Heparin bolus 5000 IU then infusion titrated to APTT (Start at 15U/kg/h, APTT 50-90 (RNSH) or 60-80 (LITFL))
- Correct underlying contributors - dehydration etc
- Morphine/Fentanyl
Retrieval to subspecialty service
PromptList Interventional procedures used in acute limb ischaemia
ResponseCatheter directed (intra-arterial) thrombolysis
Catheter Embolectomy
Surgical embolectomy
Bypass
Catheter Embolectomy
Surgical embolectomy
Bypass
PromptPost reperfusion complications
ResponseCompartment syndrome
Hyperkalaemia
Acidosis
Re-occlusion ischaemia
Rhabdomyolysis, myoglobinuria
Renal failure
Myocardial depression and hypotension
Hyperkalaemia
Acidosis
Re-occlusion ischaemia
Rhabdomyolysis, myoglobinuria
Renal failure
Myocardial depression and hypotension