II. History
- Rest pain or rest Claudication
- Onset rapid, sudden (embolic) or slowly progressive
- Cardiovascular disease (CAD, aneurysms, longstanding Diabetes Mellitus)
- Confounding diagnoses (e.g. raynaud's phenomena)
III. Exam
- Cold, painful or pale extremity
- Decreased or absent pulses
- Obtain proximal and distal pulses (bedside doppler as needed)
- Neurologic changes (nerves are most sensitive to ischemia)
- Motor weakness
- Sensory loss
- Comorbid infection findings
- Distinguish wet gangrene (aggressive management) from dry gangrene (chronic, outpatient management)
IV. Precaution: Rapid evaluation and management is critical
- Involve Intervention Radiology and vascular surgery early in suspected Acute Limb Ischemia
- Irreversible neuromuscular damage occurs within 4-6 hours of warm ischemia (room Temperature)
V. Evaluation
- Focused history and exam as above
-
Ankle-Brachial Index <0.3 (or <0.5 with other findings suggestive of Acute Limb Ischemia)
- Obtain arterial doppler, Ankle-Brachial Index (ABI) and Toe Pressures
- First-line study for most vascular surgeons
- False Negatives in stiff, non-compressible vessels (does not effect toe pressures)
- CTA Abdomen and Pelvis with limb runoff
- May be preferred definitive study in some centers if available (consult vascular surgery)
- However, additional contrast load may be significant if emergent angiogram to immediately follow
- Assign Rutherford Classification (see above)
VI. Management
- Medications
- Aspirin 325 mg orally
- Unfractionated Heparin (weight based Heparin)
- Emergent surgical interventions
- Intervention Radiology for directed arterial Thrombolysis or percutaneous thrombectomy
- Indicated for Rutherford Class I and IIa (see above)
- Vascular surgery
- Indicated for Rutherford Class IIb and III (see above)
- Intervention Radiology for directed arterial Thrombolysis or percutaneous thrombectomy
VII. References
- Lin in Herbert (2014) EM:Rap 14(4): 5-7
- Guest and DuBose (2024) EM:Rap, 9/16/2024
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Related Studies
| Concepts | Pathologic Function (T046) |
| Dutch | ischemie in kritieke ledemaat |
| German | kritische Ischaemie einer Extremitaet, kritische Ischaemie von Gliedmassen |
| Italian | Ischemia critica degli arti |
| Portuguese | Isquemia crítica do membro |
| Spanish | Isquemia crítica en un miembro, Isquemia crítica de miembro |
| Japanese | 重症虚血肢, ｼﾞｭｳｼｮｳｷｮｹﾂｼ |
| French | Ischémie critique d'un membre |
| Czech | Kritická končetinová ischemie, Kritická ischemie končetin |
| English | critical ischemia limb, critical limb ischemia, critical limb ischaemia, Critical limb ischaemia, Critical limb ischemia |
| Hungarian | Kritikus végtagi ischaemia, Kritikus végtag ischaemia |
