IBTISAM AL HOQANI

EM – R1

Outline:

Case

How case was managed

Pitfalls discussion

Brief topic talk

Take home massage

What are u going to do???

53 years old Indian man presented to A&E at 11:30 am on 25/1/2010 with bilateral lower limbs pain and swelling…

Primary Survey

Airway:

Breathing:

Circulation:

Deficit:

Exposure:

***Adjacents

History

53 yrs, Indian, not k/c/o any previous medical problem, was well until 2 weeks before presentation when he started to have on/off h/o LL pain treated in private clinic as MS pain?? and given analgesia, the pain was becoming worse untill 25/1/2010 when he present to Badr al Samawith sever bilateral lower limbs pain started early morning, associated with bilateral limb swelling, and he reffered to us as acute limb ischemia.

Cont.. History

No h/o truma

No chest pain or SOB

Other SR :unremarkable

He is working as trunk driver

Smokes 4ciggrates /day

Secondary Survey…

Head and Neck

Chest

CVS

P/A

Spine

CNS

Extremities: bilateral lower limb cyanosis and swelling with dilated veins, pulses are faint and both limb cold, no neurodefect

How he was managed?

Triage to Cubical area at 11:40am

Analgesia :morphine 10mg IV

Blood investigations sent

CT angiography LL (pt came back at 13:00)

Pt sent back to radiology department at 14:00 for

Ultrasound doppler

Seen by medical oncall: impression compartment syndrome plan to be started on anticoagulation and to be reffered to either vascular or general surgery

Cont,,,

At 14:50 pt started to have chest pain and SOB, shifted to rescues, arrested at 14:57, CPR started, (started on anticoagulation and thrombolysis)

After 15min regain pulse with low BP

Evaluated by: surgeon oncall advice IVC filter

Seen by cardiologist had bedside echo reported as sever RV hypokinesia with massive PE

Kept in A&E awaiting for bed until 17:00 when arrested again, CPR activated

Declared dead at 17:22

Management Pitfalls

BRIEF TALK

Phlegmasia CeruleaDolens

Definition:

It is a rare form of massive proximal venous thrombosis of the lower extremities associated with a high degree of morbidity and mortality, presenting with sudden severe lower extremity pain with edema and cyanosis.

Work up

Contrast venography : the gold standard, but it has technical difficulties

Duplex ultrasonography

Magnetic resonance venography (MRV) is an evolving modality of diagnostic imaging. Its principal advantage is its ability to easily reveal the proximal and distal extent of thrombus with a single study.

Treatment

Medical Therapy:

=steep limb elevation, anticoagulation with intravenous administration of heparin, and fluid resuscitation, should be the initial course of therapy

=bolus of 150 u/kg, followed by a continuous infusion of 40 u/kg/h.

Surgical Therapy:

=Surgical thrombectomy

=IVC filter application

Thrombolysis :

Systemic thrombolysis has also been used. Many authors have strongly recommended the insertion of a vena caval filter prior to initiation of thrombolytic therapy.

catheter-directed thrombolysis directly into the vein with high doses of urokinase or tissue plasminogen activator (t-PA).

intra-arterial low-dose thrombolysis via the common femoral artery

Complications

Pulmonary embolism is common, and prophylactic placement of an inferior vena cava filter is recommended in most cases.

Venous gangrene, venous congestion with massive fluid sequestration leading to circulatory collapse, and shock causing death

Amputation and death are common.

Post-phlebitic syndrome and re-thrombosis may be as high as 94% among survivors.

UP to DATE

Most patients, when diagnosed early, respond

to bed rest, extremity elevation, fluid resuscitation,

and systemic anticoagulation. If there is no response to

these measures within 12 hours, thrombolytic therapy

with catheter-based delivery should be instituted. If there

is a contraindication to thrombolytic therapy, venous

thromboectomy should be undertaken. For patients whose

condition is far advanced at presentation, thrombolytic

therapy or venous thromboectomy should be considered as

part of the initial therapeutic plan.

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Do not be missed lead by referral diagnose

Common is common but still Be highly suspicious and keep the rare condition in ur mind

As treating clinician follow ur index of suspicion and do not get influence by others

Even if A&E is busy always follow up ur patient because time is fatal