Acute Limb Ischemia

You are the vascular surgery CT1 called to A&E to review a 75-year old retired farmer who has presented with severe pain in his right foot and calf. He can pinpoint the exact moment the pain started 3 hours ago, and he denies traumatic injury. He has atrial fibrillation, hypertension and non-insulin dependent diabetes. He smokes a pipe and admits to poor compliance with his medications. How would you proceed?

Example answer introduction

In this scenario I would be most worried about acute limb ischaemia as this gentleman is an arteriopath that is poorly compliant with medications. I would assess this patient using an A-E approach, take a focused history and perform a neurovascular examination of the limb. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

Cover the patient to prevent hypothermia. 

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications – anticoagulants

  • Past medical history including previous surgery – cardiac arrhythmias 

  • Last meal

  • Events leading up to this point – time of onset, progression, history of claudication

Focussed assessment of the limb examination

I would assess the limb; 

  • 6 P’s – Pain (most important), pallor, paraesthesia, pulselessness, poikilothermia, paralysis (late sign)

  • Check ankle-brachial index (ABI) bilaterally

  • Check arterial and venous pulses with a Doppler

I would classify the limb using the Rutherford classification, start initial treatment of IV heparin and analgesia and inform the vascular registrar. 

Example questions to progress the station

Q1 The gentleman is in quite severe pain. The capillary refill time of the limb is delayed. He has partial motor weakness and some evolving loss of sensation. You can hear arterial pulses with the Doppler but are struggling to hear venous pulses. How would you proceed?

 

​Q1 - Answer

This man has grade IIb acute limb ischaemia i.e. the limb is immediately threatened as there is now evolving neurological deficit. This is a surgical emergency and I would contact the vascular registrar immediately. In the meantime, I would start treatment with IV heparin and analgesia. I would keep the patient nil by mouth and prepare him for theatre and ensure the emergency theatres and anaesthetist were aware. I would keep the patient and any relatives updated and document in the notes. 

Initial management

  • IV Heparin

  • Analgesia according to WHO pain ladder

  • Keep nil by mouth

  • Escalate to Orthopaedic Registrar 

  • Anaesthetist/Emergency theatres 

  • Keep patient and any relatives informed

  • Document, document, document!!!

 Escalation
This patient should be discussed with the vascular registrar as immediate revascularisation is indicated. This will be done by thrombectomy or bypass procedure, but this will depend on a number of factors. The strategy will depend on the presence of a neurological deficit, ischaemia duration, its localization, comorbidities, type of conduit (artery or graft) and therapy-related risks and outcomes. ​
Useful Resources

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

Acute limb ischemia. The American journal of the medical sciences

Recommended standards for reports dealing with lower extremity ischemia: revised version.

 

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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