Rosen & Barkin's 5-Minute Emergency Medicine Consult (71 page)

• Sudden onset of a cold, painful leg
  
• The 6 Ps:
  
  • Pain
    
    • Gradual, initially increasing in severity then decreasing with progressive sensory loss
      
    • Distal progressing proximally
      
    • Sudden onset with embolization
      
  • Pallor
    
  • Paresthesias
    
  • Paralysis
    
  • Pulseless (late finding)
    
  • Polar (Cold)
    
• Progressive peripheral nerve dysfunction
  
  • Early loss of proprioception and light touch
    
  • Loss of sensation and weakness follows
    
• Blue toe syndrome:
  
  • Development of blue or violaceous discoloration in one or more toes
    
  • The affected digits are often painful.
    
  • The cyanosis initially blanches with pressure or leg elevation.
    
• Signs of severe obstruction and poor prognosis
  
  • Absent capillary flow
    
  • Skin marbling
    
  • Loss of distal pulses
    
  • Paralysis
    

• Time of onset
  
• History of claudication or cramps
  
  • Reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest
    
• Past medical history to identify risk factors for thrombosis or embolus
  

• Sensory loss
  
• Muscle weakness
  
• Skin color changes
  
• Loss of pulse
  
• Signs of chronic arterial insufficiency:
  
  • Hair loss
    
  • Atrophic skin
    
• Ankle-brachial pressure index measurement
  
  • Measure arm systolic pressure with the Doppler flowmeter for accuracy
    
  • Record pressure in both arms and both tibial arteries at the ankle.
    
  • Ratio of systolic BP in the lower legs to the brachial pressure in the arm:
    
    • Place cuff above malleoli to measure pressure in lower legs
      
    • Use Doppler at posterior tibial or dorsalis pedis artery
      
  • Chronic PVD <0.9
    
  • Acute arterial occlusion <0.5
    
• Demarcation of the warm part of the extremity to the cold part to estimate level of the obstruction
  

• Electrolytes/anion gap
  
• BUN
  
• Creatinine
  
• CBC
  
• Creatine phosphokinase
  

• The utility of imaging in the ED is limited as most of the decision making is based on the clinical presentation
  
• Duplex US
  
  • Provides a “roadmap” of stenosis of the arteries of the lower extremities
    
• CT angiography
  
  • With multidetectors, performance is similar to angiography
    
  • Like angiography it requires IV contrast bolus and exposure to radiation
    
• MRI
  
  • Viable alternative to angiography.
    
  • Noninvasive
    
  • Does not required contrast material
    
• Angiography
  

• Class 1: Viable
  
  • Pain but no paralysis or sensory loss
    
  • Needs attention, not in immediate danger
    
• Class 2: Threatened but salvageable
  
  • 2A: Some sensory loss, no paralysis: No immediate threat.
    
  • 2B: Sensory and motor loss: Needs immediate treatment
    
• Class 3: Irreversible/nonviable:
  
  • Sensory loss, paralysis, absent capillary flow, skin marbling, absent arterial Doppler flow
    
  • Will require amputation
    

• Lumbar spine disorders
  
• Back pain, mechanical
  
• Decreased cardiac output owing to advanced atherosclerotic disease
  
• Frostbite
  
• Peripheral neuropathy
  
• Aneurysm, abdominal
  
• Ankle injury, soft tissue
  
• Deep venous thrombosis
  
• Septic thrombophlebitis
  
• Superficial thrombophlebitis
  
• Trauma, peripheral vascular injuries
  

TREATMENT

• Early recognition and rapid transport to an emergency department
  
• Place the limb in a dependent position
  
• Keeping the limb warm
  
• Oxygen by nasal cannula
  
• Aspirin
  

• Prompt consultation with vascular surgeon
  
• Heparin bolus followed by an infusion
  
• Class 1: Viable
  
  • Most often due to thrombosis
    
  • Intra-arterial thrombolytic agents versus surgical revascularization or endovascular repair depending on viability of limb
    
• Class 2: Threatened but salvageable
  
  • Immediate surgical revascularization
    
  • Embolectomy if indicated
    
  • Angiography and oral anticoagulation post op
    
• Class 3: Nonviable
  
  • Prompt amputation
    
  • Clinical assessment, imaging usually not required
    
• Pain control
  

• Heparin: Weight-based protocol anticoagulation with typical 80 U/kg loading bolus; 18 U/kg/h IV
  

FOLLOW-UP

• All patients with clinical diagnosis of acute arterial occlusion or (ABI <0.5) should be admitted after an emergency consultation with a vascular surgeon.
  

• Patients with chronic occlusive disease, resolved pain, and stable ABI measurements
  
• No other acute medical issues (e.g., new atrial fibrillation)
  
• Vascular surgical follow-up can be ensured.
  
• Patients should be instructed to return for any recurrent or progressive symptoms.
  

• PVD patents in which illness is not severe or acute as to require inpatient treatment may be discharged with appropriate follow-up with a vascular surgeon.
  
• Potential effects of various activities and medications on the course of their illness should be discussed.
  
• Education on smoking cessation, temperature extremes, and vasoconstricting medications should be considered.
  

• Clair D, Shah S, Weber J. Current state of diagnosis and management of critical limb ischemia.
  Curr Cardiol Rep
  . 2012;14(2):160–170.
  
• Katzen BT. Clinical diagnosis and prognosis of acute limb ischemia.
  Rev Cardiovasc Med
  . 2002;3(suppl 2):S2–S6.
  
• Setacci C, De Donato G, Setacci F, et al. Hybrid procedures for acute limb ischemia.
  J Cardiovasc Surg
  . 2012;53(1 suppl 1):133–143.
  
• Van den Berg JC. Thrombolysis for acute arterial occlusion.
  J Vasc Surg
  . 2010;52(2):512–515.
  

See Also (Topic, Algorithm, Electronic Media Element)

Peripheral Vascular Disease

CODES

• 444.9 Embolism and thrombosis of unspecified artery
  
• 444.21 Arterial embolism and thrombosis of upper extremity
  
• 444.22 Arterial embolism and thrombosis of lower extremity
  

BASICS

• Degenerative arthritis or osteoarthritis (OA) is the most common progressive joint disease, with 20–30 million cases in the US
  
• Found almost exclusively in the elderly
  

• Mechanism
  
• Repetitive stress to synovial joints associated with age
  
• May be seen in younger patients secondary to joint trauma
  
• Articular cartilage destruction:
  
  • Reactive changes in joint margin bone and subchondral sclerosis
    
• Risk factors include age, obesity, trauma, genetics, sex, and environment.