Ischemia

1. Ischemia
Dr. Hossam Ala’a
Asst. Lec. Of General Surgery
Banha Unv.

2. History taking
• Personal History ( PHx ).
• Complaint (CO).
• History of present illness ( HPI ).
• Past History ( past Hx ).
• Family History ( FHx ).

3. Personal History
• Name
• Age ( child, middle age, old age )
• Sex
• Marital status ( impotance …. !?)
• Special habits ( smoking, addict)
• Address
• Residence
• Occupation ( …..!?)
• If Female …… Menestrual history

4. Complaint
•
‫المريض‬ ‫بلفظ‬
‫إيه‬
‫الـ‬
‫جابك‬
‫؟؟‬ ‫المستشفى‬
‫؟‬
‫؟؟؟‬ ‫إيه‬ ‫قد‬ ‫بقالك‬

5. HPI
• Pain
• Swelling
• Disturbance of function
• Other systems
• Recent investigations and/or medications

6. 1- Pain :
• claudication pain
• Rest pain
• Sudden pain of acute
ischemia

7. Claudication pain :
• Site (
‫؟‬ ‫الوجع‬ ‫مكان‬ ‫فين‬
)
• Claudication distance (
‫رجلك‬
‫بتشد‬
‫تمشي‬ ‫ما‬ ‫بعد‬
‫كام‬
‫متر؟‬
)
• Radiation (
‫الوجع‬
‫بيسمع‬
‫في‬
‫حته‬
‫تانيه‬
‫؟‬
)
• Onset (
‫؟‬ ‫بالتدريج‬ ‫وال‬ ‫واحدة‬ ‫مره‬ ‫حصل‬
)
• Course (
‫بيزيد‬
‫وال‬
‫بيقل‬
‫وال‬
‫زي‬
‫؟‬ ‫هو‬ ‫ما‬
)
• Duration (
‫؟‬ ‫إيه‬ ‫قد‬ ‫بقاله‬
)
• Association (
‫معاه‬
‫؟‬ ‫ورم‬
)
• What increase (
‫إيه‬
‫الـ‬
‫بيزوده‬
‫؟‬
)
• What decrease (
‫إيه‬
‫الـ‬
‫بيقلله‬
‫؟‬
)
• Severity (
‫؟‬ ‫الوجع‬ ‫شدة‬
)
• Time & time of rest (
‫الوجع‬ ‫وقت‬
‫و‬
‫الوقت‬
‫الـ‬
‫بتحتاجة‬
‫يروح؟‬ ‫عشان‬
)

8. rest pain :
• Site (
‫؟‬ ‫الوجع‬ ‫مكان‬ ‫فين‬
)
• Radiation (
‫الوجع‬
‫بيسمع‬
‫في‬
‫حته‬
‫تانيه‬
‫؟‬
)
• Onset (
‫؟‬ ‫بالتدريج‬ ‫وال‬ ‫واحدة‬ ‫مره‬ ‫حصل‬
)
• Course (
‫بيزيد‬
‫وال‬
‫بيقل‬
‫وال‬
‫زي‬
‫؟‬ ‫هو‬ ‫ما‬
)
• Duration (
‫؟‬ ‫إيه‬ ‫قد‬ ‫بقاله‬
)
• Association (
‫معاه‬
‫؟‬ ‫ورم‬
)
• What increase (
‫إيه‬
‫الـ‬
‫بيزوده‬
‫؟‬
)
• What decrease (
‫إيه‬
‫الـ‬
‫بيقلله‬
‫؟‬
)
• Severity (
‫؟‬ ‫الوجع‬ ‫شدة‬
)

9. sudden pain of acute ischemia:
• Site (
‫؟‬ ‫الوجع‬ ‫مكان‬ ‫فين‬
)
• Radiation (
‫الوجع‬
‫بيسمع‬
‫في‬
‫حته‬
‫تانيه‬
‫؟‬
)
• Onset (
‫؟‬ ‫بالتدريج‬ ‫وال‬ ‫واحدة‬ ‫مره‬ ‫حصل‬
)
• Course (
‫بيزيد‬
‫وال‬
‫بيقل‬
‫وال‬
‫زي‬
‫؟‬ ‫هو‬ ‫ما‬
)
• Duration (
‫؟‬ ‫إيه‬ ‫قد‬ ‫بقاله‬
)
• Association (
‫معاه‬
‫زرقاء‬ ‫كالكيع‬ ‫أو‬ ‫ورم‬
‫بتروح‬
‫و‬
‫تيجي‬
‫؟‬
)
• What increase (
‫إيه‬
‫الـ‬
‫بيزوده‬
‫؟‬
)
• What decrease (
‫إيه‬
‫الـ‬
‫بيقلله‬
‫؟‬
)
• Severity (
‫؟‬ ‫الوجع‬ ‫شدة‬
)

10. 2- swelling :
• Site (
‫؟‬ ‫فين‬ ‫مكانه‬
)
• Size (
‫؟‬ ‫إيه‬ ‫حجمه‬
)
• Onset (
‫إكتشفتها‬
‫إزاي‬
‫؟‬
( )
‫بالصدفه‬
,
‫بسرعه‬
,
‫ببطئ‬
)
• Course (
‫وال‬ ‫بتزيد‬
‫بتقل‬
‫وال‬
‫ثابته‬
‫ساعات‬ ‫وال‬
‫و‬
‫؟‬ ‫ساعات‬
)
• Duration (
‫؟‬ ‫إيه‬ ‫قد‬ ‫بقالها‬
)
• Other swellings (
‫معاها‬
‫كالكيع‬ ‫أي‬
‫تانيه‬
‫؟‬
)
• What increase (
‫إيه‬
‫الـ‬
‫بيزودها‬
‫؟‬
)
• What decrease (
‫إيه‬
‫الـ‬
‫بيقللها‬
‫؟‬
)
• Effect on general condition (
‫تتحرك؟‬ ‫قادر‬ ‫مش‬
)
• Apparent cause (
‫إتخبطت‬
,
‫إتعورت‬
,
‫خدت‬
‫حقنة‬
,
‫عينة؟‬ ‫سحبت‬
)

11. 3- Disturbance of function :
Skin:
• Trophic changes (
‫؟‬ ‫وقع‬ ‫رجلك‬ ‫شعر‬ ‫أو‬ ‫رفع‬ ‫جلدك‬
)
• Color changes (
‫جلدك‬ ‫لون‬
‫اتغير‬
‫؟‬
)
• Sence of coldness (
‫حاسس‬
‫رجلك؟‬ ‫في‬ ‫ببرودة‬
)
Nails:
• Loss of luster (
‫ظوافرك‬
‫بهتت‬
‫؟‬
)
• Fissured (
‫ظوافرك‬
‫شققت؟‬
)
• Brittle (
‫ظوافرك‬
‫هشة‬ ‫بقت‬
‫و‬
‫بتقع‬
‫لوحدها؟‬
)

12. SC tissue:
(
‫رجلك‬ ‫شكل‬
‫و‬
‫صوابعك‬
‫الرجل‬ ‫عن‬ ‫أختلف‬
‫التانية‬
‫؟‬
)
• Decrease limb cicumference
• Thin tapering toes
Nerves (sensory)
(
‫تقف‬ ‫لما‬
‫بتحس‬
‫رجليك‬
‫زي‬
‫بعض؟‬
)
• Paraesthesia
• Hypoesthesia
• Hyperesthesia
Muscle (motor)
(
‫من‬ ‫أكتر‬ ‫رجل‬ ‫على‬ ‫بتحمل‬
‫التانية‬
‫ماشي؟‬ ‫وأنت‬
)
• Weakness
• paralysis

13. Gangrene:
(
‫صباعك‬
‫إسود‬
‫؟‬
)
• Site
• Duration
• Relation to trauma
Veins:
• Migrating thrombophlebitis
(
‫زرقاء‬ ‫حاجات‬
‫و‬
‫بتوجع‬
‫بتيجي‬
‫؟‬ ‫تروح‬ ‫و‬
)
• Hx. Of DVT
(
‫وجعتك‬ ‫رجلك‬
‫و‬
‫اتحجزت‬
‫المستشفى‬ ‫في‬
‫خدت‬
‫هيبارين‬
‫؟‬
)

14. Bones:
(
‫حاسس‬
‫عظمك؟‬ ‫في‬ ‫بنشر‬
)
• Sawing pain
Joints:
(
‫حاسس‬
‫مفاصلك‬ ‫في‬ ‫بوجع‬
‫و‬
‫تحركها‬ ‫قدر‬ ‫مش‬
‫زي‬
‫األول؟‬
)
• Limitation of movement
Brain:
(
‫جالك‬
‫إغماء‬ ‫نوبات‬
‫و‬
‫كدا؟‬ ‫قبل‬ ‫منها‬ ‫بتفوق‬
)
• TIAs.
• Hemiplegia
• Blindness
• fainting

15. 4- Review of other systems :
 Ask about ischemia in other parts of the body:
• GIT
Cramping pain in abdomen in relation to meals
• Respiratory system
Cough, dyspnea, tachypnea, hemoptysis…etc.
• CVS
Chest pain, HF, AF, rheumatic heart…etc.
• Urogenital
Loin pain, dysuria, hematuria, impotence…etc.
• CNS
Loss of memory, fainting, blindness, hemiparasis…etc.
• Musculoskeletal
Muscle, bone or joints pain

16. 5- History of investigations or medications :
Recent …

17. Past History
• Past medical history :
 Similar attacks
 Chronic diseases : (DM, HTN, DVT, TB, HCV, HBV, HIV)
• Past surgical history :
 Previos operation
• Drug history
 Types
 Allergy
• Blood transfusion
• Old trauma
 A-V fistula

18. Family History
• Similar condition
• Consanguinity
• Irrelevant

19. Examination
• General examination
• Local examination
• Special investigation
• Provisional diagnosis

20. General (3)
• Body built, Decubitus, Facial expressions
• Complexion  (3 colors)
Pallor.
Cyanosis.
Jaundice.
• Chest, Abdomen, Extremities
• Pulse, bl. pressure & temprature

21. Pt. is alert, conscious, oriented to time, place &
persons.
Average build, normal decubitus, quite facial
expression.
Average intelligence & he/she is cooperative.

22. Local
• Exposure
• Combined inspection & palpation
• Special tests
• auscultation

23. 1- Exposure :
If LL (most common)
From umbilicus downward
If UL (less common )
Poth UL including H&N till nipples

24. 2- Combined inspection & palpation:
I- Both limbs are not symmetrical
II- Localized swelling in femoral triangle,
popliteal fossa and cubital fossa.
(aneurysm)
• Comment on:
number
Site
Size
Shape

25. III- Skin overlying :
• Color changes:
Pallor, cyanosis
Mottling, green, broun or black
• Trophic changes:
Dry, thin, shinny
Loss of hair & trophic ulcer

26. • Gangrene:
Site
Extent
Characters
Type
o Dry or moist
o Septic or aseptic
Line of demarcation & separation

27. Color changes: notice effect of position
• Buerger’s test:
Pt. lies on back & raising the affected limb 
Pallor (measure the angle)
• Dependency test:
Pt. lies on back & drops the affected limb below
the level of bed 
Cyanotic and congested (measure the time)

28. Skin temperature: after exposure for 5 min.
• In both limbs
• Start from distal to poximal
• Site of change in temp. = level of ischemia

29. IV- Muscle:
Examine >>> tone, state, passive movement,
active movement & power :
• Power … weak distally
• Movement (
‫رجله‬ ‫يحرك‬
,
‫يحرك‬
‫صوابعه‬
)
 Aortic block ..Limitation of hip movement
 Femoral block ..Limitation of knee movement
 Popliteal block ..Limitation of ankle movement
• Muscle wasting
What’s the 1st. Muscle affected in Leriche $ ??

30. V- Nerve: ( pin prick test )
• Both limbs
• Start from distal to proximal
• Paraesthesia or sesory loss  distal to
obstruction.
VI- Veins:
• Palpate veins for superficial thrombophlebitis
• DVT

31. VII- Arteries:
• Palpate arterial pulsatons on both limbs
• Compare both side Rt. And Lt. 
 Force of pulsation
 Vessel wall
 Presence of thrill
• Palpate different artries at different sites
• If in doubt, simultaneously feel your pulse &
compare with the Pt. pulse
VIII- Examine any ulcer, swellings, or
edema.

32. Sites of arterial pulsation
• Dorsalis pedis : lat. To tendon of ext. hallucis
longus .
• Posterior tibial : behind med. Malleolus.
• Popliteal : in popliteal fossa with 90 degree
flexed knee.
• Femoral : femoral triangle just below mid
point of inguinal ligament in flexed, abducted
and ext. rotated thigh.

33. • Radial : lower part of radial aspect of front of
forearm.
• Ulner : lower part of ulner aspect of front of
forearm.
• Brachial :
Lower part : in cubital fossa medial to biceps
tendon.
Upper part : just post. To biceps Ms. In groove
bet. Biceps and triceps
• Axillary : in axilla

34. • Carotid :
CCA : along the ant. Border of sternomastoid
Ms. Below the upper border of thyroid
cartilage.
ECA: along the ant. Border of sternomastoid
Ms. above the upper border of thyroid
cartilage.
• Superficial temporal : in front of tragus

35. Special tests
 Harvey’s venous refilling time:
Elevate the limb to empty the veins and then
place it down flat on the bed & estimate the
venous filling time :
Normally : 5-10 seconds
Prolonged : in ischemia
N.B: some prefer to lower the limb below the
level of the bed.

36.  Capillary circulation test:
• Note the effect of pressure on the nail bed
skin.
• Normally pressure causes blanching.
• Release of pressure is followed by immediate
return of normal color.
• Slow return of color indicates a sluggish
capillary circulation.
• Failure of blanching  the part is gangrenous.

37.  Addison’s test:
• Done in case of UL. Ischemia
• The shoulders are placed backwards.
• The patients take a deep breath with the arm
pulled downwards and the chin turn upwards and
to the affected side
N.B: some prefer to tilt the head to the opposite
side.
• The radial pulse may be weakened or obliterated
in case of cervical rib or scalene syndrome.

38. 3- Auscultation :
• Along the course of the vessels ( systolic bruit in
case of aneurysm or stenosis )
 Auscultatory test :
• To detect the site of arterial obstruction.
• The main vessel is occluded by pressure while
stethoscope over the vessel  release pressure
Loud sound  vessel is patent
Nothing heard  vessel is obstructed

39. special investigations
• Lab. :
CBC, coagulation profile, KFT, LFT, RBS
• ECG
• Radiological :
Doppler & doplex US
CT angio.
MRA
X-ray

40. Provisional diagnosis
• Etiological  atheroslerosis or Burger’s Ds.
• Anatomical  UL or LL
• Pathological  acute or chronic
• Functional  degree of ischemia & level of
arterial obstruction.
• Complicalion  gangrene  moist or dry , septic
or aseptic.
• Association  DVT, TB, DM, HF, AF, pulm. HTN …

41. How to detect degree of ischemia ?
• Claudication time (short … long)
• Claudication distant (short … long)
• Time of rest pain (short … long)
• Color changes (pallor … cyanosis … fixed)
• Sensation (paraesthesia … loss)
• Burger’s angel (small … large)
• Venus filling time (short … long)
• Capillary filling (rapid … sluggish)

42. How to detect level of arterial
obstruction ?
• History :
Maximum site of claudication
• Examination :
Site of change of temperature.
Sile of muscle weakness
Site of sensory loss
Site of loss of arterial pulsation
• Investigations .

43. THANK YOU
See you soon ..