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ACUTE LIMB ISCHAEMIA
Dr. JoelArudchelvam
ConsultantVascular andTransplant Surgeon
Teaching HospitalAnuradhapura
Acute limb Ischaemia
 Sudden interruption of blood supply to
limb resulting in threat to the limb
viability.
Acute limb Ischaemia
Differentiating thrombosis and
embolism
Sudden onset pain Sub acute onset
Young patient Elderly patient
Has a source of em...
Sources of emboli
 Heart – recent MI, Atrial fibrillation,Valvular
heart disease.
 Blood vessels – aneurysms
 An embolu...
Acute limb Ischaemia
Presentation
“ P ”s
 Pain
 pallor
 Perishing cold
 Pulselessness
 Paresis / paralysis
 Paraesth...
Acute limb Ischaemia
Management
 Recognize
 Start unfractionated heparin
 Loading dose 75 – 100 IU/Kg ( approximately 5...
Acute limb Ischaemia
 Surgery
 Embolectomy with fogarty
catheter
 Can be done under LA
Post operative management
 Monitor distal pulse
 Keep foot elevated
 Monitor movements and sensation
 Continue Heparin...
Complications of Acute limb
Ischaemia
 Limb loss
 Death
 Compartment syndrome
 Reperfusion effects
 Volkmann ischemic...
Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
 Systemic...
Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
DURING ISCHAEMIA
DURING ISCHAEMIA
AFTER REPERFUSION
AFTER REPERFUSION
MANAGEMENT OF REPERFUSION EFFECTS
MANAGEMENT OF REPERFUSION EFFECTS
Reperfusion effects
 Systemic
 Substances Released
 Lactic Acid
 K+
 Inflammatory Mediators
 Myoglobin
 Activated L...
Reperfusion effects
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failur...
Management and prevention of
Reperfusion syndrome
 Cardiac – IV fluids and inotropes
 Respiratory – KeepO2
 Renal – hyd...
Reperfusion effects
 Mangement
 Ligation of vessel if not
responding to other supportive
measures
Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.
 Compartment Perfusion Pressure...
Compartment syndrome
Causes
 Trauma (muscle contusion)
 Haematoma
 Reperfusion
 Intracompartmental extravasation of fl...
Compartment syndrome
Clinical features
 Excessive pain - pain on passive movements
 Numbness -e.g. anterior compt. first...
Compartment syndrome
Treatment
 Recognize
 Reduce intracomparmental pressure
 Remove bandages and cast
 Keep limb elev...
Compartment syndrome
Treatment
Compartment Syndrome
Fasciotomy
Volkmann ischaemic
contracture
Thank You
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definition of acute limb ischaemia , causes, clinical features, management of embolism, reperfusion injury

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Acute limb ischaemia

  1. 1. ACUTE LIMB ISCHAEMIA Dr. JoelArudchelvam ConsultantVascular andTransplant Surgeon Teaching HospitalAnuradhapura
  2. 2. Acute limb Ischaemia  Sudden interruption of blood supply to limb resulting in threat to the limb viability.
  3. 3. Acute limb Ischaemia
  4. 4. Differentiating thrombosis and embolism Sudden onset pain Sub acute onset Young patient Elderly patient Has a source of emboli* No source of emboli No history of occlusive arterial disease History of occlusive arterial disease Other pulses are present Other pulses may be absent
  5. 5. Sources of emboli  Heart – recent MI, Atrial fibrillation,Valvular heart disease.  Blood vessels – aneurysms  An embolus gets stuck at sites of bifurcation as the diameter of the vessels reduces at these places.
  6. 6. Acute limb Ischaemia Presentation “ P ”s  Pain  pallor  Perishing cold  Pulselessness  Paresis / paralysis  Paraesthesia / anaesthesia. Beware  After trauma  After anaesthesia  Acute limb ischemia is a clinical diagnosis -there is no need of imaging.
  7. 7. Acute limb Ischaemia Management  Recognize  Start unfractionated heparin  Loading dose 75 – 100 IU/Kg ( approximately 5000 IU )  Followed Infusion of heparin -18U/kg (approximately - 1000U/hr)  Refer to vascular surgeon  Pain relief  Keep fasting  Inform theatre and anaesthetist  Consent – for embolectomy and fasciotomy  Check theViability of the limb - note.
  8. 8. Acute limb Ischaemia  Surgery  Embolectomy with fogarty catheter  Can be done under LA
  9. 9. Post operative management  Monitor distal pulse  Keep foot elevated  Monitor movements and sensation  Continue Heparin – 18U/kg per hour infusion  Start warfarin when surgical bleeding is not a concern  Monitor for reperfusion effects
  10. 10. Complications of Acute limb Ischaemia  Limb loss  Death  Compartment syndrome  Reperfusion effects  Volkmann ischemic contracture
  11. 11. Reperfusion effects  Local  Reperfusion injury – paradoxical death of already dying muscles after reperfusion  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure
  12. 12. Reperfusion effects  Local  Reperfusion injury – paradoxical death of already dying muscles after reperfusion
  13. 13. DURING ISCHAEMIA
  14. 14. DURING ISCHAEMIA
  15. 15. AFTER REPERFUSION
  16. 16. AFTER REPERFUSION
  17. 17. MANAGEMENT OF REPERFUSION EFFECTS
  18. 18. MANAGEMENT OF REPERFUSION EFFECTS
  19. 19. Reperfusion effects  Systemic  Substances Released  Lactic Acid  K+  Inflammatory Mediators  Myoglobin  Activated Leucocytes  Etc.
  20. 20. Reperfusion effects  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure  Ect
  21. 21. Management and prevention of Reperfusion syndrome  Cardiac – IV fluids and inotropes  Respiratory – KeepO2  Renal – hydration, Monitor IP/ OP, dialysis  Correct electrolyte abnormalities – K+  Continue mannitol for 48 hours
  22. 22. Reperfusion effects  Mangement  Ligation of vessel if not responding to other supportive measures
  23. 23. Compartment syndrome Reduced organ perfusion due to increased intra compartment pressure.  Compartment Perfusion Pressure (CPP)  MeanArterial Pressure (MAP)  Intra Compartmental Pressure (ICP) CPP = MAP – ICP
  24. 24. Compartment syndrome Causes  Trauma (muscle contusion)  Haematoma  Reperfusion  Intracompartmental extravasation of fluids  Tight bandage, cast
  25. 25. Compartment syndrome Clinical features  Excessive pain - pain on passive movements  Numbness -e.g. anterior compt. first toe web (deep peroneal N )  Tense swollen leg  Do not look for absent distal pulse – late
  26. 26. Compartment syndrome Treatment  Recognize  Reduce intracomparmental pressure  Remove bandages and cast  Keep limb elevated Fasciotomy
  27. 27. Compartment syndrome Treatment
  28. 28. Compartment Syndrome Fasciotomy
  29. 29. Volkmann ischaemic contracture
  30. 30. Thank You
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definition of acute limb ischaemia , causes, clinical features, management of embolism, reperfusion injury

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