Ischaemia John Gan Vascular Surgeon Specialists Without Borders Seminar in Surgery Rwanda September 2010 Acute ischaemia The six Ps Pain Paralysis Pallor Pulseless Parasthaesia Pins and needles ID: 558509
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Slide1
Acute Limb
Ischaemia
John GanVascular Surgeon
Specialists Without
Borders
Seminar
in Surgery
Rwanda, September 2010Slide2
Acute
ischaemia
The six PsPainParalysis
PallorPulseless
Parasthaesia
(Pins and needles)
Poikylothermia
(Perishingly cold)
Chronic ischaemiaClaudicationRest painUlcersGangrene
www.specialistswithoutborders.orgSlide3
Acute limb
ischaemia
Challenging problemMortality rate 25%
Limb amputation rate 35%
www.specialistswithoutborders.orgSlide4
Acute Limb
Ischaemia
Sudden arterial occlusionTissue hypoperfusion
Ischaemic symptoms
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Acute limb
ischaemia
Rapid occlusion leads to severe ischaemia
the 6 PsSlow onset occlusion allows collateral formation and mild ischaemia
claudication
rest pain
gangrene
www.specialistswithoutborders.orgSlide6
Acute limb
ischaemia
4 to 6 hours ischaemic time causes irreversible effects
Propagation of thrombusOcclusion of outflow vessels
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Acute limb
ischaemia
Compartment syndromeReperfusion injury
Systemic effects
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Common causes
Embolism
ThrombosisTrauma
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Other causes
Thrombophilia
Other vasculopathy
AneurysmCompression syndromesvasculitis
Intra arterial injection
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Presentation
Emergency
UnmistakableThe six Ps
PainParalysis
Pallor
Pulseless
Parasthaesia
(pins and needles)Poikylothermia
(perishingly cold)
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Differential diagnosis
Venous
ischaemiaNeurological condition
Low flow states
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Natural history
Non salvageable limb
Limb lossDeath
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Assessment
History
ExaminationSpecial testing
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History
Degree of disability
Time factorsPossible causes
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Examination
Assess the affected limb
The 6 psCompare to the “normal limb”
Assess the whole patient
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Examination
The six Ps
PainParalysisPallor
PulselessParasthaesia (pins and needles)
Poikylothermia
(
perishingly
cold)
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Three groups of cases
Viable
ThreatenedSalvageable with immediate treatmentSalvageable with timely treatment
Non salvageable
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Viable
Limb still warm
Movement and sensation intactPain moderate or resolving
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Threatened
immediate treatment required
Six Ps presentAbsent movementAbsent sensation
Less than 4 to 6 hoursThreatened timely treatment required
Moderate pain
impaired movement
impaired feeling
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Non salvageable
Six Ps
greater than four to six hoursFixed staining of skinWoody feel to limb
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Degree of
ischaemia
and causationEmbolismTrauma
Acute on chronic
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Special testing
Hand held
dopplerDuplex ultrasoundAngiography
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Management
Viable cases
Observation
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Management
Non salvageable cases
Amputation
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Management
Threatened cases
RevascularisationEmbolectomy
BypassThrombolysisCompartment syndrome
fasciotomy
Systemic supportive therapy
Cardiac/respiratory/renal
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Summary
Arterial occlusion
CausationEmergencySix Ps
Three categoriesAppropriate treatment
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1. Acute occlusion of a previously normal artery results in severe
ischaemic
symptoms because:
a. it occurs without warning b. occlusion of a normal artery is rare
c. there are few collateral vessels to supply the limb
d. embolism cannot occur in a diseased artery
2. Compartment Syndrome occurs in the
ischaemic limb: a. leading to a reduction in pain b. because ischaemic muscle shrinks c. when muscle is re-
perfused after a period of ischaemia d. due to reduced blood flow
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3
. Acute limb
ischaemia caused by embolism occurs due to:
a. acute thrombosis of a chronic stenosis
b. occlusion of an artery when clot travels from one site to another
c. thrombosis of an aneurysm
d. clot moving from the venous to arterial circulation in some cases
4
. Features of an acutely ischaemic limb requiring immediate treatment include:
a. complete paralysis b. complete sensory loss c. absent pulse and Doppler signal d. all of the above
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