47. Leg pain/swelling Flashcards
Differentials for leg pain/swelling
Venous
- DVT
- Post-thrombotic syndrome
- Venous insufficiency
Arterial (PAD)
- intermittent claudication
- Critical limb ischaemia
- acute limb ischaemia
Infection
- cellulitis
- septic arthritis/osteomyelitis
what score should you calculate if DVT is a ddx
Two-level DVT Wells score
DVT likely: 2 points or more
DVT unlikely: 1 point or less
how many points is ‘likely’ for dvt on two level wells score? management
2 or more
1. a proximal leg vein ultrasound scan should be carried out within 4 hours
- if +ve = start anticoagulant
- if -ve = a D-dimer test should be arranged. A negative scan and negative D-dimer makes the diagnosis unlikely and alternative diagnoses should be considered
- If proximal leg vein ultrasound cannot be performed within 4 hours then a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
- rivaroxaban or apixaban
- if the scan is negative but the D-dimer is positive:
stop interim therapeutic anticoagulation
offer a repeat proximal leg vein ultrasound scan 6 to 8 days later
how many points is ‘unlikely’ for dvt on two level wells score? management?
- perform a D-dimer test
- this should be done within 4 hours. If not, interim therapeutic anticoagulation should be given until the result is available
if the result is positive then a proximal leg vein ultrasound scan should be carried out within 4 hours
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered whilst waiting for the proximal leg vein ultrasound scan
if the result is negative then DVT is unlikely and alternative diagnoses should be considered
How long should anticoagulation be continued DVT
provoked - 3 months
active cancer - 3-6 months
unprovoked - 6 months
define provoked dvt
due to an obvious precipitating event
e.g. immobilisation following major surgery.
The implication is that this event was transient and the patient is no longer at increased risk
what score should be used to assess bleeding risk anticoagulation
ORBIT score
presentation post-thrombotic syndrome
post dvt
Venous outflow obstruction and venous insufficiency result in chronic venous hypertension.
The resulting clinical syndrome is known as post-thrombotic syndrome. The following features maybe seen:
painful, heavy calves
pruritus
swelling
varicose veins
venous ulceration
management post-thrombotic syndrome
compression stockings
what is peripheral arterial disease
Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas.
It usually refers to the lower limbs, resulting in symptoms of claudication.
what is intermittent claudication? features
is a symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
what is critical limb ischaemia? features?
end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.
The features are pain at rest, non-healing ulcers and gangrene. There is a significant risk of losing the limb.
what is acute limb ischaemia
Rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
define gangrene
death of the tissue, specifically due to an inadequate blood supply
non-modifiable risk factors peripheral arterial disease
Older age
Family history
Male
modifiable risk factors peripheral arterial disease
Smoking
Alcohol consumption
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress
Examination and invetsigation intermittent claudication
examianiton
- check pulses
- ABPI
invetsigation
1. duplex ultrasound
2. magnetic resonance angiography (MRA) should be performed prior to any intervention
first line imaging intermittent claudication
duplex ultrasound
Management of intermittent claudication
- Supervised exercise program (+lifestyle particularly smoking)
- Refer for consideration of angioplasty or bypass surgery
- Consider naftidrofuryl oxalate (vasodilator) , review after 3-6 months
Managing CVS risk - secondary prevention
Managing CVS risk secondary prevention peripheral arterial disease
- Assess for cardiovascular conditions
- Comorbidities should be treated, including
hypertension
diabetes mellitus
obesity - Smoking cessation
Diet
Statin - atorvastatin 80mg
Clopidogrel
features critical limb ischaemia
1 or more of :
Rest pain in foot for more than 2 weeks
Ulceration
Gangrene
HoPC: Patients often report hanging their legs out of bed at night to ease the burning pain
what ABPI suggests claudication
0.6-0.9
what ABPI suggests critical limb ischaemia
< 0.5
Management critical limb ischaemia
- Urgently refer to vascular MDT
+ Manage pain : paracetamol and either weak or strong opioids depending on severity
+ Refer to specialist pain management
how may severe PAD be treated by vascular
endovascular revascularization if <10cm
(angioplasty and stenting)
surgical revascularization if >10cm
(surgical bypass with an autologous vein or prosthetic material)
Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.
define angioplasty
using a balloon to stretch open a narrowed or blocked artery
6 Ps of acute limb ischaemia
Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold
Management of ?acute limb ischaemia
ABC approach
analgesia: IV opioids are often used
intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery
- emergency referral to on-call vascular team
Definitive management:
intra-arterial thrombolysis
surgical embolectomy
angioplasty
bypass surgery
amputation: for patients with irreversible ischaemia
initial investigations acute limb ischaemia
handheld arterial Doppler examination
If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained.
causes of acute limb ischaemia
thrombus (due to rupture of atherosclerotic plaque)
embolus (e.g. secondary to atrial fibrillation)
factors suggesting thrombus cause of acute limb ischaemia
pre-existing claudication with sudden deterioration
no obvious source for emboli
reduced or absent pulses in contralateral limb
evidence of widespread vascular disease (e.g. myocardial infarction, stroke, TIA, previous vascular surgery)
factors suggesting embolus for acute limb ischaemia
sudden onset of painful leg (< 24 hour)
no history of claudication
clinically obvious source of embolus (e.g. atrial fibrillation, recent myocardial infarction)
no evidence of peripheral vascular disease (normal pulses in contralateral limb)
evidence of proximal aneurysm (e.g. abdominal or popliteal)
when is endovascualr repair the most app choice for severe PAD/critical limb ischaemia?
short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
when is open surgical techniques (surgical revascualrisation more app for severe PAD/ CLI
long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
investigations?thrombophlebitis
- USS to exclude dvt
- ABPI to exclude PAD, especially imp as compression stockings can worsen PAD
management thrombophelbitis
- NSAIDs
- compression stockings
- consider LMWH
thrombophlebitis presentation
burning pain over vein, red skin, worm like mass that is hard
