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Intermittent claudication, pain at rest, paresthesias, muscle weakness, paralysis
PE : Absence of pulses, Cool and pale or mottled skin, Reduced sensation,
2 point discrimination (more sensitive than light touch), Decreased strength.
6 P : Paresthesia, Pain, Pallor, Pulselessness, Poikilothermia, Paralysis
Major causes of acute limb ischemia :
- Acute thrombosis (arterial thrombus, thrombosed graft)
- Embolism (Afib, prosthetic valve)
- Aortic dissection to limb
- DVT causing limb ischemia by arterial vasospasm (phlegmasia cerulea dolens)
- Compartment syndrome
Acute -> No collateral blood vessels
Prompt revascularization :
Catheter-based thrombolysis, thrombectomy, surgical reconstruction
Critical limb ischemia caused by chronic disorders :
ischemic pain at rest or tissue loss (non-healing ulcers or gangrene)
related to peripheral artery disease
Other causes of limb ischemia :
Severe atherosclerosis, thromboangiitis obliterans,
other vasculitis, connective-tissue disorders.
Other causes of limb ischemia include atheroembolism,
vasospasm, the compartment syndrome,
phlegmasia cerulea dolens (DVT with severe leg swelling compromising perfusion),
and vasopressor drugs.
Acute Treatment :
ASA, Unfractionated Heparin (UFH) 80U/kg bolus, then 18U/kg/h
ample pain meds, urgent surgical consult for endovascular or surgical revascularization.
* UFH may inhibit clot propagation and further distal thrombosis, but no established benefit in literature.
What about thrombolysis for Acute Limb Ischemia ?
While not superior to surgery, it may be the treatment of choice in patients with occluded grafts,
collaterals and chronic insufficiency, or for occlusions of small, inaccessible arteries.
Reperfusion injury :
Profound limb swelling with dramatic increases in compartmental pressures.
- Severe pain, hypoesthesia, and weakness of the affected limb
- Myoglobinuria, elevation of CPK
Since the anterior compartment of the leg is the most susceptible,
assessment of Peroneal-nerve function
(Motor : dorsiflexion ; Sensory : dorsum of foot and first web space)
The diagnosis is made primarily from the clinical findings
but can be confirmed if the compartment pressure > 30 mm Hg
Long term oral anticoagulation
https://emergencymedicinecases.com/episode-28-aortic-dissection-acute-limb-ischemia-compartment-syndrome/
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