interesting case rounds rebecca burton-macleod r4, emergency medicine aug 3, 2006
TRANSCRIPT
Interesting Case Rounds
Rebecca Burton-MacLeod
R4, Emergency Medicine
Aug 3, 2006
History
• 81M• CC: numbness in left arm and SOBOE• HPI: symptoms started suddenly while pt
was swimming 4hrs earlier– “clumsiness” in L arm– Diaphoretic, dizzy– 2d hx of SOBOE– No specific chest pain
History cont’d
• No palpitations
• No headache
• Normal left leg function, normal speech/ vision
• No previous similar symptoms
PMHx
• Paroxysmal Afib• Pacemaker x 10yrs• Angina 20yrs prior• CHF• Scrotal hernia• BPH and TURP
• Meds:– Lasix
– Warfarin
– Fosinopril
– Bisoprolol
– Taking all meds regularly
On exam:• Vitals: Afebrile, P 105 irreg, BP (R arm) 152/80, R
23, sats 92% r/a• Normal HS, no murmurs• JVP ~3cm ASA, mild bilateral pitting edema to LE• Lungs—dec A/E to R base• Abdo—soft, non-tender• Neuro—CN normal, normal tone, power, reflexes;
sl decreased sensation entire L arm• MSK—no bony tenderness L arm, full ROM
Any thoughts ?
Investigations ?
• CBC, lytes, Cr, INR/PTT, TNT (4hour)
• EKG
• CXR
Test results
• Normal CBC
• Normal lytes, Cr
• TNT negative
• INR 1.2
• EKG—Afib, T wave inversion in V4-6 (new compared to previous EKG)
CXR
Any further thoughts ?
Management ?
Case cont’d
• No signif improvement
• Continues to c/o “clumsiness” in L arm
CT head
Re-examine pt
• C/o coolness in L arm
• Decreased radial/brachial pulses in L arm
• Pt had presented to ED ~1mo ago with epistaxis– Nose packed– Vit K given to reverse warfarin (INR >9)
CT angio
• “saddle-like” intraluminal filling defect in L main PA with extension filling L upper lobe arterial branches
CT angio 14.5cm L distal axillo-brachial artery occlusion
Problem list
• CHF
• Afib
• PE
• L ischemic arm
• Low INR
Management
• Pt admitted to Vascular service
• Heparinization started
• Pt underwent L brachial embolectomy the following day
• Long term anticoagulation (with close monitoring to ensure therapeutic INR !)
Acute upper limb ischemia
Acute upper limb ischemia
• Is far more uncommon than lower limb ischemia– Upper extremity has good collateral circulation and low
rate of atherosclerosis
• Responsible for ~15% of vascular procedures for ischemic limbs
• Of all embolization sites, upper extremity cases accounts for only 8%
• Functional limb impairment occurs in ¾ of cases if left untreated
Upper extremity anatomy
Causes • Main causes of upper limb ischemia:
– Thromboembolic disease– Traumatic injuries– Aortic dissection – Atherosclerosis and chronic limb ischemia– Subclavian steal s/o– Thoracic outlet s/o– Iatrogenic causes
Upper limb ischemia
Ali, T et al. Vasc Surg. 2001.
Thromboembolic events
• 62% of pts have associated Afib
• 84% have associated CAD
Differentiation of Thrombus vs. Embolus
• Embolus– Usual identifiable source
for embolus (Afib)
– Rarely hx of claudication
– Few findings suggestive of occlusive disease
– Sharp demarcation of ischemia
– Minimal atherosclerosis, sharp cutoff, few collaterals on arteriography
• Thrombus– Less common to find
identifiable source for embolus
– Often hx of claudication– Often findings suggestive of
occlusive disease (contralateral limb pulses diminished/absent)
– Diffuse ischemia– Diffuse atherosclerosis,
tapered irregular cutoff, well-developed collaterals on arteriography
Rosen’s. Ch 82.
Diagnosis
• 5 P’s:– Pain– Pallor– Pulselessness– Paresthesias– Paralysis
Rutherford ClassificationRutherford Classification
____CompleteCompleteCompleteCompleteAbsentAbsentPrimary Primary amputation req.amputation req.
IrreversibleIrreversibleIIIIII
AudAud__PartialPartialPartialPartialSlow/absentSlow/absentSalvagableSalvagable if if treated treated emergentlyemergently
ThreatenedThreatenedIIbIIb
AudAud__PartialPartial--Intact/slowIntact/slowSalvagableSalvagable if if treatedtreated
ThreatenedThreatenedIIaIIa
AudAudAudAud----IntactIntactNot immediately Not immediately threatenedthreatened
ViableViableII
VVAASensory Sensory lossloss
ParalysisParalysisCap. refillCap. refillDescriptionDescriptionCategoryCategory
DopplerDoppler
Acute limb ischemia
Management
• For limb-threatening ischemia:– Emergency Fogarty catheter embolectomy– +/- vascular bypass grafting if in situ
thrombosis as cause of ischemia– If above measures fail, then primary amputation
Heparin ?
• Should be started immediately
• 80U/kg IV bolus, then 18U/kg/h maintenance infusion
• Minimizes clot propagation and obviates further embolism
• No formal studies done to establish beneficial role
GP IIb-IIIa antagonist ?
• Pilot trial randomized 70 pts to urokinase + abciximab vs. urokinase + placebo– Amputation-free survival at 90d was 96% with
GP IIb-IIIa group vs. 80% with placebo– More rapid thrombolysis in first group, but also
higher rate of non-fatal major bleeding
Thrombolysis ?
• May be considered in non-limb-threatening ischemia (takes 6-72h for effect)
• Therefore, most useful if known thrombosis
• IV thrombolysis initially used, but now mostly replaced by catheter-directed thrombolysis
Thrombolysis ?
• One trial comparing IA streptokinase, IA rt-PA, and IV rt-PA– Angiographic success rates 80% vs. 100% vs.
45%– 30 day limb salvage rates 60% vs. 80% vs. 45%
respectively
• Comparison of rt-PA with urokinase showed faster lysis with rt-PA but 24h and 30d clinical success rates were similar
Clogett GP et al. Chest. Sept 2004.
Surgery vs. thrombolysis
• Cochrane Review 2006.– 5 trials with 1283 participants– No signif difference in limb salvage or death at
30d, 6mos, 1yr– Thrombolysis was significantly associated with
higher stroke rates (1.3%), major hemorrhage (8.8%), distal embolization (12.4%)
– Concluded insufficient evidence to advocate for universal initial treatment
Case conclusion
• Pt felt to have developed thromboembolic disease resulting in L ischemic arm and PE– Likely due to subtherapeutic INR– ? Due to epistaxis and vitamin K administration
Vitamin K to reverse anticoagulation
DeLoughery TJ et al. Crit Care Clin. July 2005.
Questions ?