"Time is life and limb" in acute limb ischemia.In my talk I will briefly review the vascular anatomy of the extremities, along with the causes and mimickers of ALI. The focus will be on the Emergency Department recognition and management of this disease. I'll also discuss a little about the dilemmas that the vascular surgeons face with regards to inpatient management. Should the treatment be catheter-directed thrombolysis (intra-arterial injection of thrombolytic agents), percutaneous thrombectomy, open thrombectomy, or limb amputation?
Here's a quick synopsis of my take-home points:
- To diagnose ALI, obtain an ankle-brachial index (ABI) measurements.
- When listening for arterial blood flow using the Doppler, document not only the presence of arterial flow but also the sound waveform heard. Normal arterial flow should be triphasic. Notice how stenotic arterial blood flow sounds monophasic:
Normal triphasic arterial Doppler flow
Stenotic monophasic arterial Doppler flow
Venous Doppler flow
- Determine the ALI grade on the Rutherford classification scheme. Grades I and IIA generally benefit from catheter-directed thrombolysis (in the interventional radiology suite). Grade IIB generally requires open thrombectomy in the operating room. Grade III generally requires limb amputation.
Click on table to view see larger font.- When you diagnose ALI, the ED management includes: aspirin, unfractionated heparin, dependent positioning of the extremity, pain control, and avoiding extremes of temperature.