| What is the prognosis for a limb that is irreversibly damaged? | major tissue loss or permanent nerve damage inevitable | DESCRIPTION AND PROGNOSIS SENSORY LOSS MUSCLE WEAKNESS ARTERIAL DOPPLER VENOUS DOPPLER Limb viable, not immediately threatened None None Audible Audible Audible Audible Audible Usually inaudible Inaudible Inaudible None Minimal (toes) or none Mild or moderate Profound, paralysis (rigor) More than toes, associated with rest pain Profound, anaesthetic Limb marginally threatened, salvageable if promptly treated Limb immediately threatened, salvageable with immediate revascularization Limb irreversibly damaged, major tissue loss or permanent nerve damage inevitable | 513 | summary | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | DESCRIPTION AND PROGNOSIS SENSORY LOSS MUSCLE WEAKNESS ARTERIAL DOPPLER VENOUS DOPPLER Limb viable, not immediately threatened None None Audible Audible Audible Audible Audible Usually inaudible Inaudible Inaudible None Minimal (toes) or none Mild or moderate Profound, paralysis (rigor) More than toes, associated with rest pain Profound, anaesthetic Limb marginally threatened, salvageable if promptly treated Limb immediately threatened, salvageable with immediate revascularization Limb irreversibly damaged, major tissue loss or permanent nerve damage inevitable | 1 | page=1,block=14 | 0.700 | valid |
| What are the five P’s to remember in vascular occlusion? | Pain, Pallor, Pulselessness, Paresthesia, and Paralysis | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. In advanced cases, there may be frank gangrene EMBOLIC: Embolism from the heart or atherosclerotic aorta. Embolus may arise from heart in case of atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis THROMBOSIS: Acute thrombosis of a limb artery may occur at the site of a pre-existing atherosclerotic plaque Sharp or penetrating injury BLUNT INJURY: Traction injury or contusion | 227 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. |
| What are the potential sources of embolism in vascular occlusion? | Embolism from the heart or atherosclerotic aorta | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. In advanced cases, there may be frank gangrene EMBOLIC: Embolism from the heart or atherosclerotic aorta. Embolus may arise from heart in case of atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis THROMBOSIS: Acute thrombosis of a limb artery may occur at the site of a pre-existing atherosclerotic plaque Sharp or penetrating injury BLUNT INJURY: Traction injury or contusion | 438 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | In advanced cases, there may be frank gangrene EMBOLIC: Embolism from the heart or atherosclerotic aorta. | 1 | page=1,block=39 |
| What complications can revascularization in advanced ischemia cause? | hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 75 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 1 |
| What conditions in the heart can lead to an embolus in vascular occlusion? | atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. In advanced cases, there may be frank gangrene EMBOLIC: Embolism from the heart or atherosclerotic aorta. Embolus may arise from heart in case of atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis THROMBOSIS: Acute thrombosis of a limb artery may occur at the site of a pre-existing atherosclerotic plaque Sharp or penetrating injury BLUNT INJURY: Traction injury or contusion | 528 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | Embolus may arise from heart in case of atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis THROMBOSIS: Acute thrombosis of a limb artery may occur at the site of a pre-existing atherosclerotic plaque Sharp or penetrating injury BLUNT INJURY: Traction injury or contusion |
| What imaging techniques are used to assess embolism or thrombosis? | CT angiography, MR angiography, catheter angiography | i. Vascular repair (Stage I, IIa, IIb ischemia), Amputation (Stage III ischemia) ii. Concomitant bone/nerve injury should be managed simultaneously iii. Supportive treatment, pain relief/antibiotic prophylaxis Stage III Stage I, IIa, IIb Stage III EMBOLISM THROMBOSIS Surgical Embolectomy/Catheter directed Thrombolysis (send retrieved thrombus for microscopic/microbiological /histopathological examination Investigate the cause of embolism (cardiac/aortic) and manage accordingly Amputation Thrombolysis/Heparinization Radiological imaging (CT angiography, MR angiography, catheter angiography) Surgical/Endovascular Revascularization Amputation | 543 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | Supportive treatment, pain relief/antibiotic prophylaxis Stage III Stage I, IIa, IIb Stage III EMBOLISM THROMBOSIS Surgical Embolectomy/Catheter directed Thrombolysis (send retrieved thrombus for microscopic/microbiological /histopathological examination Investigate the cause of embolism (cardiac/aortic) and manage accordingly Amputation Thrombolysis/Heparinization Radiological imaging (CT angiography, MR angiography, catheter angiography) Surgical/Endovascular Revascularization Amputation |
| What laboratory findings are associated with compartment syndrome? | Myoglobinuria and elevation of the creatine kinase level | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 356 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 1 | page=1,block=5 |
| What are the signs of vascular occlusion? | Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. In advanced cases, there may be frank gangrene EMBOLIC: Embolism from the heart or atherosclerotic aorta. Embolus may arise from heart in case of atrial fibrillation, acute myocardial infarction, mitral stenosis, left ventricular dysfunction, left atrial myxoma, prosthetic heart valves or endocarditis THROMBOSIS: Acute thrombosis of a limb artery may occur at the site of a pre-existing atherosclerotic plaque Sharp or penetrating injury BLUNT INJURY: Traction injury or contusion | 89 | list | 0.780 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | SYMPTOMS Pain at rest, paresthesia, muscle weakness/paralysis of the affected limb SIGNS Absence of pulses distal to the occlusion, cool and pale or mottled skin, reduced sensation and decreased strength REMEMBER THE FIVE P’S: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis* *The last two may or may not be present depending upon extent and duration of vascular occlusion. |
| What are the symptoms of compartment syndrome? | Severe pain, hypoesthesia and weakness of the affected limb | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 289 | list | 0.780 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | REPERFUSION INJURY • Revascularization in advanced ischemia can also cause hyperkalemia, acidosis, myoglobinuria and cardiopulmonary depression • Patients require monitoring, proper hydration COMPARTMENT SYNDROME • Can occur in Stage II ischemia due to revascularization edema • Symptoms: Severe pain, hypoesthesia and weakness of the affected limb • Lab: Myoglobinuria and elevation of the creatine kinase level • Four-compartment fasciotomy to be performed when there is even an iota of doubt | 1 | page=1,block=5 |
| What supportive treatments are recommended for sharp or penetrating injuries? | pain relief/antibiotic prophylaxis/tetanus prophylaxis | A. SHARP/PENETRATING INJURY i. Control bleeding by applying pressure bandage over the wound ii. Resuscitation iii. Vascular repair (Stage I, IIa, IIb ischemia), Amputation (Stage III ischemia) iv. Concomitant bone/nerve injury should be managed simultaneously v. Supportive treatment, pain relief/antibiotic prophylaxis/tetanus prophylaxis | 285 | list | 0.740 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726643577_2_acute_limb_ischemia.pdf | Supportive treatment, pain relief/antibiotic prophylaxis/tetanus prophylaxis | 1 | page=1,block=54 | 0.700 | valid |