A VIOLACEOUS CATASTROPHE

Abstract

Introduction: Acute limb ischemia (ALI) is an emergent medical condition warranting time- sensitive intervention. Early recognition of presentation is integral for limb loss prevention and prompt management of its catastrophic complications.

Case and Result: A 89-year-old patient was referred to emergency department for bluish discoloration of left leg for one week. Her past medical history included hypertension, gout and Alzheimer’s disease. She was seen 1 week prior in private clinic with history of intermittent pain and bluish discoloration over sole of left foot in which she was discharged home with no intervention. She presented again with aggravation of the pain and blue purplish discoloration up to her knee. Her left leg popliteal and pedal pulses were absent. A diagnosis of acute limb ischemia was made followed by an urgent referral to the vascular team. Intravenous infusion of heparin was promptly initiated, unfortunately, she developed cardiac arrest and succumbed to death despite resuscitation.

Discussion: The 6 Ps (Paresthesia, pain, pallor, pulselessness, poikilothermia, paralysis) comprises the classical presentation of ALI patient. The assessment of patients with suspected ALI should also include palpation/ auscultation of Doppler pulses for determination of perfusion pressure via ankle-brachial index (ABI) ratio. Adequate perfusion pressure is maintained when ratio exceeds 0.9. Initial treatment for any suspected ischemic extremity should consist of immediate administration of weight- based IV heparin bolus (80 units/kg) and associated continuous IV infusion (18 units/kg/hour) barring any contraindications. Immediate full dose heparinization can result in symptomatic improvement either from anticoagulation effects of heparin or volume expansion. It may also prevent proximal and/or distal thrombus propagation and preserves the microcirculation. The extremity should also be placed in dependent position to maximize perfusion and have any constriction removed while maintaining the limb at warm temperature. Patients should then be assessed for definitive treatment which may consist of percutaneous angioplasty, bypass grafting or even amputation.

Conclusion: Attention to ALI patient should not be directed only to the limb at risk but to patients’ general clinical condition. Resuscitation of ongoing ischemia includes addressing concurrent shock, acidosis and arrhythmias.