ACUTE LIMB ISCHEMEA

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CASE PRESENTATION ACUTE LIMB ISCHEMIA :

CASE PRESENTATION ACUTE LIMB ISCHEMIA BY DR. HASAM ASHRAF SURGICAL UNIT II

HISTORY:

HISTORY My pt. asifa begum 65y female married presented through M/E on 15/7/08 with presenting complaint of PALPITATIONS FOR 1 DAY She was admitted in M/E & was diagnosed as a case of ATRIAL FIBRILLATION She was managed in EMERGENCY when she suddenly developed PAIN IN RT. UPPER LIMB 2 HOURS

HISTORY OF PRESENT ILLNESS:

HISTORY OF PRESENT ILLNESS Pain was Sudden in onset Severe in intensity Burning in nature Getting worse with time Aggravated with activity Not relieved with analgesics, elevation or hanging of limbs. It was associated with abnormal sensation of pins & needles & blue discoloration of finger

HISTORY OF PRESENT ILLNESS:

HISTORY OF PRESENT ILLNESS It was not associated with intermittentent claudication , transient ischemic attack, any unusual posture or exercise. No history of blue discolration of fingers with cold or any neck swelling

PowerPoint Presentation:

PAST HISTORY DM + HTN + IHD + for 10 years No previous operative history or any other illness PERSONAL HISTORY Non smoker, no alcohol intake or any drug abuse & was house ambulator. DRUG HISTORY Poor compliance for diabetes & HTN No history of antiplatet/anticoagulant therapy SOCIOECONOMIC Middle class

PowerPoint Presentation:

FAMILY HISTORY No history of peripheral vascular disease , aneurysm , arterial or venous thrombosis.

GENERAL PHYSICAL EXAMINATION:

GENERAL PHYSICAL EXAMINATION Pulse 110/min. Irregularly irregular(normal limb) Affected limb with no radial or brachial JVP not raised. Temp. 98.6 Respiratory rate 15/min. B.P 100/70 No pedal/sacral edema NO OTHER FINDING

SYSTEMIC EXAMINATION:

SYSTEMIC EXAMINATION CVS ON INSPECTION no precarium bulging ,no visible pulsation, scar mark. ON PLAPATION apex beat in 5 th left intercostal space medial to mid- clavicular line with normal character , no para-sternal heave or thrill palpable ON AUSCULTATION irregular heart sounds Rest of examination (systemic) was normal

LOCAL VASCULAR EXAMINATION:

LOCAL VASCULAR EXAMINATION ON INSPECTION Active movement of hand painful Blue discoloration of fingers & hand No amputated digits or scar mark No tissue loss or ulceration or gangrene was present ON PALPATION Limb was cold Delayed capillary refill Radial Ulnar Brachial not palpable Intact sensation

LOCAL VASCULAR EXAMINATION:

LOCAL VASCULAR EXAMINATION ON AUSCULTATION No subclavian bruit CONTRALATERAL UPPER LIMB WITH NO DEFECT

PROVISIONAL DIAGNOSIS:

PROVISIONAL DIAGNOSIS ACUTE LIMB ISCHEMIA (ARTERIAL EMBOLUS)

EMERGENCY INVESTIGATIONS:

EMERGENCY INVESTIGATIONS ROUTINE CBC S/E RFT CXR- ECG-P wave absent QRS rapid & irregular SPECIAL Absent radial ulnar & brachial artery on Doppler USG

PLAN:

PLAN EMBOLECTOMY

OPERATION:

OPERATION Pt was given IV bolus of heparin Adequately hydrated Control of blood glucose & optimizing the oxygen saturation OPERATIVE PROCEDURE Embolectomy ( fogarty catheter) 3 x 3 cm clot retrieved proximally and distally no clot retrieved

RESPONSE:

RESPONSE ON TABLE : SYMPTOMS RELIEVED PERIPHERAL PULSES RETURNED

FOLLOW UP:

FOLLOW UP Anticoagulation with heparin continued untill pt is ambulatory ECHOCARDIOGRAPHY

Pathophysiology:

Pathophysiology Embolus (dislodges from luminal surface) Arterial tree Lodges at luminal narrowing

PATHOPHYSIOLOGY :

PATHOPHYSIOLOGY

Sites:

Sites 90 %........ Vessels of lower limb (bifurcation of aorta/ femoral/ popliteal are principal sites of impaction)

SITES:

SITES

Clinical Features:

Clinical Features Pain Pulse less Pallor Paraesthesia Paralysis Perishing cold

DIFFERENCE BETWEEN ARTERIAL EMBOLUS AND ARTERIAL THROMBOSIS :

DIFFERENCE BETWEEN ARTERIAL EMBOLUS AND ARTERIAL THROMBOSIS

Classification:

Classification

Treatment:

Treatment Anticoagulation therapy

Embolectomy:

Embolectomy

Intra-arterial Thrombolysis:

Intra-arterial Thrombolysis

Summary:

Summary Atrial Fibrillation Pain, paraesthesia , discolouration of skin, cold pulse less upper limb Embolectomy ( 3 x 2 cm clot retrieved) Return of peripheral pulses

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