Vascular Disasters Take Home Points
- Consider vascular pathologies in all of your patients with atraumatic limb pain – especially those with typical and atypical risk factors
- 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
- Perform vascular exam on every patient with pain
- 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
- YouTube: Triphasic Arterial Flow
- emDocs: Acute limb ischemia
- emDocs: Acute limb ischemia Pearls and Pitfalls
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/.