March 11, 2020

REBEL Core Cast 29.0 – Vascular Disasters

Vascular Disasters Take Home Points

  1. Consider vascular pathologies in all of your patients with atraumatic limb pain – especially those with typical and atypical risk factors
  2. Early diagnosis is imperative. Time is tissue. Catch this as early as possible. Pain is the earliest symptom. First presents with pain then paresthesia then paralysis
  3. Perform vascular exam on every patient with pain
  4. If concerned for ischemic limb, call the vascular surgeon and get patient to CT for imaging of aorta and affected limb. 

REBEL Core Cast 29.0 – Vascular Disasters

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Challenges of Vascular Disasters

  • Delayed or missed diagnosis because the presentation can be atypical.
  • Time is tissue; a delay is associated with increased morbidity and mortality

Vascular Emergencies

  • Acute Ischemic Limb
  • Aortic Catastrophes
    • DIssection
    • Aneurysm
  • Thrombosed popliteal artery aneurysm
  • Phlegmasia Cerulea Dolens

Acute Ischemic Limb

  • Abrupt cessation of blood flow to an extremity
  • Two most common causes (up to 80% of all cases)
    • Embolism (usually from heart or aorta)
    • In situ thrombus (usually someone with chronic atherosclerosis)
  • Presentation is varied and can be diagnosed clinically

Classic Risk Factors

  • Preexisting Atherosclerosis
    • CAD, PAD, Previous strokes
  • Diabetes Mellitus
  • Smoking
  • If a patient has arterial disease in one part of their body they’re likely to have it everywhere.

Atypical Risk Factors

  • Diseases that cause chronic inflammation appear to be significant risk factors that are under-recognized.
  • HIV (doesn’t matter if on antiretroviral therapy or not)
  • Rheumatologic diseases like lupus and rheumatoid arthritis
  • Any patient with risk for venous thromboembolism (pregnancy, malignancy)

Presentation

  • Remember the 6 P’s
    • Pallor, pain, paresthesia, paralysis, pulselessness, and poikilothermia
    • However, these are late signs (particularly paralysis, pulselessness and poikilothermia). By the time these signs develop, the limb may be past the point of salvage
  • Pain is the first symptom
    • Due to pain fibers being unmyelinated and being very susceptible to ischemia
    • Pain out of proportion to examination is often seen
  • Paraesthesia and Paralysis are later findings
    • Paralysis is due to irreversible tissue loss and limb will need to be amputated

Physical Exam

  • The general appearance of limb in question and make sure to compare to contralateral limb
  • Is limb cold or warm
  • Is limb pale / mottled / cyanotic
  • Preexisting arterial disease likely if
    • Smooth shiny leg
    • Chronic wounds that won’t heal
  • Palpate pulses – make sure to compare to contralateral limb
    • If unable to palpate -> grab doppler
    • Doppler Results
      • Triphasic is normal
      • Monophasic or absent is abnormal
      • Biphasic can be either normal or abnormal

Abnormal Exam, Next Step

  • Clinical diagnosis of ischemic limb, patients leg is having a stroke
  • Call Vascular surgeon
  • Order Heparin drip
  • Get stat CTA
    • Gives consultant more information like where the occlusion is located and how many there are
    • PEARL: When getting CTA make sure to scan the vessels feeding into the limb.
      • I.e. if you are worried about limb ischemia, make sure to scan from the abdominal aorta down looking for pathology
  • Ultrasound
    • Great for a lot of vascular issues and has doppler functions which are very helpful
    • Limitations
      • Quality of scan is operator dependent and patient body habitus
      • Not great for vessels in pelvis and distal to popliteal fossa

More Reading/Listening

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 29.0 – Vascular Disasters", REBEL EM blog, March 11, 2020. Available at: https://rebelem.com/rebel-core-cast-29-0-vascular-disasters/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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