REBEL Core Cast 29.0 – Vascular Disasters

Posted by Marco Torres on Mar 11, 2020

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.

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

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.

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)

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

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

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