Slide of Acute limb ischemia (diagnosis, complication, management)

Slide of acute limb ischemia for educational purpose

1. ACUTE LIMB IS C HEMIA

2. Case presentation A 70 YEAR OLD FEMALE CAME TO CASUALITY WITH COMPLAINS OF SUDDEN ONSET OF PAIN IN LEFT LEG APPROXIMATELY ONE HOUR AGO. ON EXAMINATION THERE WERE ABSENT POPLITEAL AND LOWER PULSATIONS, DECREASED SENSATION OF LEFT LEG AND IT WAS COLD AND PALE AS COMPARED TO THE RIGHT LEG PREMORBIDLY PATIENT HAS HISTORY OF ISCHEMIC HEART DIEASE AND KNOWN CASE OF HYPERTENSION AND TYPE 2 DIABETES MELLITUS NO HISTORY OF TRAUMA/ CLAUDICATION. FEVER/ INTRA-VASCULAR PROCEDURES

3. BLOOD SUPPLY OF LOWER LIMB

4. DEFINITION Sudden decrease in limb perfusion that threatens the viability of the limb. Complete or even partial occlusion of the arterial supply to a limb can lead to  Rapid ischemia  Poor functional outcomes within hours. Acute limb ischemia has an incidence of around 1.5 per 10,000 person year.

5. Aetiology Its causes can be classified into 3 main groups: Embolization  Thrombosis in situ  Trauma (less common), including compartment syndrome

6. Clinical features

7. Rutherford classification

8. INVESTIGATIONS

9. FBC, RP, PT/PTT cardiac enzymes (AMI with mural thrombus) serum lactate (to assess the level of ischaemia) thrombophilia screen (if <50yrs without known risk factors) BLOOD INVESTIGATION

10. ECG Ankle brachial index be d side Doppler ultrasound scan (both limbs) CT angiography

11. Normal CT angio

12. Occlusion of right superifical femoral artery

13. MANAGEMENT

14. Acute limb ischaemia is a surgical emergency. Complete arterial occlusion will lead to irreversible tissue damage within 6 hours. A therapeutic dose heparin or intravenous heparin infusion should be initiated as soon as is practical Give IV heparin bolus 3000-5000 units (80 units/kg) Follow with IV heparin infusion at 1000 units/hour (18 units/kg/hr) Ideal PTT is 2 to 2.5 times normal (60-80 sec) Avoid clot propagation

15. Thrombolysis

16. Embolectomy  via a Fogarty catheter; this can be done over a wire using radiological guidance

17. Angioplasty

18. Complications

19. Mortality rate of around 20% Important complication of acute limb ischemia -  Reperfusion injury •Release of substances from the damaged muscle cells, such as: •K+ ions causing  hyperkalaemia •H+ ions causing acidosis •Myoglobin, resulting in significant AKI

20. Summary