Thursday, 23 May 2019

Vascular Ischaemia

Physical Exam
Cardiac - murmur, AD
Extremity - look for signs of chronic peripheral vascular disease
Neurological - sensory and motor loss
Vascular - grade peripheral pulses
ABPI

Amputations are more common with thrombotic occlusions.
Emboli are different - and most often from the heart and comprised of platelets. They can also come from aneurysms - and will be made of atheroma.
Vasculitis, iatrogenic, compartment syndrome, aortic dissection are also risk factors.

Upper arm emboli are less common. Thoracic outlset syndrome may masquerade - pressure on the subclavian artery from a cervical rib or abnormal soft tissue band may lead to a dilatation lined with thrombus, predisposing to occlusion or embolisatoin.  Popliteal aneurysms are very likely to be dislodged.

PAIN - worse on movement, and relieved by hanging your legs over the edge. Tenderness on examination is often due to muscle death.
PALLOR - limbs are often white. Chronically ischaemic limbs may turn sunset pink due to compensatory response. Dry gangrene is black, and a sign of chronic ischaemia for more than two weeks.
PARAESTHESIA-
PERISHINGLY COLD - compare
PULSELESSNESS - use dopplers

Check bloods including a creatinine kinase.

Treatment: Analgesia, Oxygen, 5000 units IV heparin, heparin infusion, IV fluids
   Unless bleeding, pregnant, CVA/TIA, tumour, previous GI bleed, trauma

References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117769/
https://www.rcemlearning.co.uk/references/acute-limb-ischaemia/
https://learning.bmj.com/learning/module-intro/aae-arterial-disease.html?moduleId=10057018&searchTerm=%E2%80%9Cvascular%E2%80%9D&page=1&locale=en_GB

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