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Mr Johnson aged 57 presents to A&E with leg pain. You are the FY1 clerking him in.

What would you do?

ABC!
Alert & conversational but in obvious pain.

History
SOCRATES Differentials tool

Skin shingles, trauma, burns, cellulitis, oedema Tissue bruising, swelling Blood vessels ischaemia, DVT, varicose veins Nerves compartment syndrome Muscles trauma, strain Ligaments/tendons sprain, rupture Bone fracture (pathological/non)

Pt c/o pain in lower left leg, sudden onset. Prior to this - claudication and rest pain for several weeks. What else is important in an ischaemic Hx? Rest pain, night pain, exercise tolerance and cardiovascular risk factors

Age Male Smoking Diabetes Cholesterol Hypertension FHx Ethnicity Obesity Other CV disease Erectile dysfunction!

6Ps of ischaemia

Look for ulcers Tissue loss (i.e. amputations) Scars (previous surgery) Buergers test/angle End pieces?

Pale Paraesthesia Pain Pulseless Perishingly cold Paralysis (poor prognosis)

ABPI >0.9 0.6-0.9 0.3-0.6 <0.3

Clinical status Normal Intermittent claudicant Rest pain Impending gangrene

MR angiography Contrast angiography

Acute limb ischaemia

Usually embolic, no Hx of intermittent claudication


Background atherosclerosis, present at critical stage Intermittent claudication + sudden onset worsened or persistent pain

Chronic limb ischaemia

Acute on chronic limb ischaemia

Immediate - IV heparin Definitive - Surgery


Embolectomy Thrombectomy Bypass Endarterectomy Angioplasty

Patient brought to A&E Obese 68 year old man, severe abdo pain, pale, sweaty, very unwell What are you going to do??...

ABC!! A speaking to you B RR 30 shallow breathing, sats 85% on air C BP 75/42 (was 85/50 5 mins ago!), HR 125, cap refill 7secs D GCS 14/15 E tender, pulsatile abdomen What is going on and what do you do next?

Oxygen 15litres, non-rebreathe Wide bore cannula x2 Bloods: X match 4-8units, clotting, FBC, U&E, amylase Fluid resus colloid stat, keep systolic <100 TRANSFUSE CALL VASCULAR SURGEONS!

If his AAA had been discovered earlier what could have been done?
Normal size For surveillance, reduce CV risk factors Surgery recommended

< 3cm 3- 5.4cm

5.5 cm

Venous Ulcer

Neuropathic ulcer

Arterial Ulcer

Marjolins Ulcer - SCC

Arterial Site Distal, dorsum of foot/ toes Smaller Irregular borders Grey/blue

Venous Gaitor area

Neuropathic Pressure points Small Punched out Not always visible, foreign bodies present Deep sinus Painless

Other (Malignant) Anywhere, can be at site of other ulcers Increasing size Rolled/ hard & raised Necrotic and sloughy variable Painless

Size Borders Base

Larger Irregular Granulating tissue Shallow Can be painful Venous eczema, haemosiderin

Depth Tender? Surrounding skin

Medium Can be painful Hair loss, champagne bottle leg

Venous compression stockings (check ABPI first!), treat varicose veins Arterial revascularise, debride, reduce CV RFs Neuropathic diabetic control, good foot care, foreign body removal! Other biopsy & treat as per malignant dermatological condition

Risk factors? Occupations with prolonged standing, pregnancy, intra abdominal mass, obesity, age, female (x6 risk), previous DVT Examination what should you include?

What is the name of this test?

Trendelenburgs test

Conservative compression stockings, lose weight, reduce standing! Surgical Sclerotherapy, laser therapy, High tie/ stripping

High pressure within a compartment of limb causing compromise to neurovascular supply Hx recent limb trauma/ surgery
Pain out of proportion to event

Examination
Pain on passive flexion

Investigation
Measure compartment pressures

Management
Fasciotomy

Dialysis Fistula

What is this and how is it classified?

Aortic Dissection

Stanford Type A involves ascending aorta (DeBakey I & II) Type B Does not involve ascending aorta (DeBakey III)

Left above knee amputation

Right forefoot amputation

What symptoms is this patient likely to be complaining of?

Intermittent claudication, night pain & rest pain

Gangrene critical limb ischaemia

What might this patients ECG show?

AF throwing off embolus causing acute limb ischaemia