fuegorama said:
BKN-
What hint were you going to give?
Oh, I was just going to suggest that at that point you knew:
1. The legs were swollen
2. One leg was cold
3. And there were no pulses except a weak one in the left femoral
And I was going to say, does it sound like the problem is
A) arterial
B) local
C)venous?
I think we're doing a poor job of teaching vascular disease to medical students. Younger docs tend to concentrate on the swelling and erythema (if any) and come to DVT or cellulitis. They are pretty common. However, given the facts above, the patient has to have peripheral arterial occlusion. He could have the others also, but you should use Occam's razor.
The real issues for diagnosis are whether the occlusion is acute or chronic, thromobotic or embolic, and at what level. Finally, is immediate surgery or embolectomy indicated? If the pain was of sudden onset, you've got about 2-3 hours to save the leg. More often, this is a subacute to chronic process.
The symptom of pain relieved on dependency is useful, if present. I doubt that it's sensitive enough to be reliable.
The 2 questions I would have asked would be: "Are you impotent?", "Do you have pain in your buttocks on walking?". If he answered yes to both in combination with an absent femoral pulse, you've defined LeRiche's syndrome. LeRiche described it as diagnostic of occlusion of the aotro-iliac bifurcation. I've think it reliable.
There's also a cheap and easy way to get a functional evaluation of the LE arterial tree.
1. If the pulses at the feet are bounding, there is no significant large vessel occlusion.
2. If the pulses are not easily found, get a blood pressure cuff and a doppler. Put the cuff on the mid-calf and find the PT or DP with the doppler. Pump the cuff up to occlude the vessel, then drop it down until hear the sounds again. That's the systolic pressure. Put that pressure over the brachial systolic to get the ankle/brachial index. Normal is .9-1.2. If this is what you get, the swelling (usually from chronic venous insufficiency) was hiding the normal pulses.
I hope you all have been taught this already.
Now the good part,
1. It the ABI was normal, but you have strong reason to believe that the patient has peripheral arterial disease, have him walk around the ED for 5 minutes. Immediately repeat the ankle pressures, often the pressure will have fallen precipitously, indicating a functional deficit. Refer the patient.
2. If the ABI was abnormal, Repeat the process with the cuff on the lower thigh and upper thigh. Draw out a diagram showing the pressures at each level. A drop of 30 torr across a single segment tells you that there is a significant occlusion:
Brachial to high thigh: aorto-iliac or iliac bifurcation
high thigh to low thigh: femoral bifurcation
low thigh to ankle: trifurcation
Always do both LEs. If there is disease on one side there is almost always disease on the other.
All this in 10 minutes without an image. This is how we did it before doppler ultrasound. When I was a surgical tern on a big vascular service, we did this to everybody referred to us. It was surprisingly accurate when compared to the arteriograms. Actually, when there was a discrepancy, it was because the arteriogram was showing us a clinically unimportant lesion.
The other part to remember is that diabetics also have small vessel disease. This often leads to failure when attempting to revascularize the larger vessels. The vascular labs even have this cute little 1 cm wide toe cuff to be placed around the great toe with a tiny strain gauge to measure the arterial wave. they can then generate a toe/ankle index to measure small vessel occlusion.
Anyway, enough said. As always, ask a simple question, you get a pageant.
