Atraumatic leg pain Flashcards
Acute ischaemic leg: revascularisation required in what time frame to save the limb?
Within 4-6 hours!!
3 most common causes of acute ischaemic leg (non-traumatic)
Embolus
Thrombus
Graft/angioplasty occlusion
acute ischaemic leg: most common source of embolus
Cardiac - e.g. AF/ post-MI
Most common at artery bifurcations
If thrombus is the cause of acute ischaemic leg, what is likely to be seen in the other limb?
History of PAD
Features of chronic vascular insufficiency in the other limb
acute ischaemic leg:
Embolus presentation
How does the other leg appear?
Acute onset
Limb appears WHITE (no collateral circulation)
Other leg usually normal
acute ischaemic leg: Thombus presentation
Why may symptoms be less severe than in embolus?
the other leg
More gradual onset
Collateral circulation usually ell-defined in people with PAD
Pulses in other leg may also be absent
Investigations in suspected acutely ischaemic leg
CXR, ECG, USS
Bloods: FBC, Us+Es, CK, cross-match
Signs of chronic vascular insufficiency
Muscle wasting, hair loss, arterial ulcers
Buerger’s angle
Lift leg until foot goes pale (not the angle), hang off side of bed and watch recoloration - >15 seconds indicates severe ischaemia (may also go v red)
Initial management of acute ischaemic limb (think A+E)
Analgesia - IV opioid
Correct any hypovolaemia
Contact vascular surgery!!
Definitive management of acutely ischaemic limb
REVASCULARISATION!!
In acute limb ischaemia, how can revascularisation be achieved?
What happens if the limb is unsalvegable
Endovascular (percutaneous catheter-directed thrombolysis)
Surgical (thromboembolectomy)
If unsalvegable, requires amputation
Definitive management of PAD
Angioplasty/ bypass surgery (only after lifestyle advice + exerise programme)
PAD: what can be given if patient does not want angioplasty/ bypass?
Naftidrofuryl oxalate
What is gout?
Disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) & the deposition of urate crystals in joints & other tissues
What is the role of xanthine oxidase in the body?
Metabolises xanthine (produced from purines) into uric acid
In gout, why can’t urate be excreted properly? (2)
Either too much being made or kidneys can’t keep up with the demand
What are the 3 phases of gout
Asymptomatic hyperuricaemia
Period of acute attacks (usually last 1-2 weeks), plus intervals with no symptoms
Chronic tophaceous gout
Biggest RF for gout
HYPERURICAEMIA
usually due to impaired renal excretion of urate
4 other RFs for gout
Inc age
Male
Alcohol
HTN
What lifestyle advice would you give someone with gout?
Weight loss
Smoking cessation
Avoid purine-rich foods (e.g. red meat + anchovies)
Which 2 joints are most commonly affected by gout?
1st MTP
Knee
Presentation of gout
Sudden onset, severe joint pin
Red, hot + swollen joint
Tophi What are they? When do they develop? Where? Are they painful?
Firm, white nodules under translucent skin
Usually develop after 10 years
Over extensors
Usually not painful
In gout, when are serum uric acid levels measured?
4-6 weeks after an attack
What PMH is important to ask about in suspected gout?
History of renal stones
Management of a gout attack
NSAID or oral colchicine
How long after a gout attack are NSAIDs continued for?
1-2 days
Gout attack: alternative if NSAID not tolerated
Steroid
Gout attack: adjunct pain relief
Paracetamol
What is 1st line for urate-lowering therapy?
What class of drug
When should it be started?
Allopurinol
Xanthine oxidase inhibitor
Start AFTER acute attack has resolved
What is the most common SE of allopurinol?
Rash
2 most common causes of septic arthritis
Staph + strep
Investigations in suspected septic arthritis
Bloods: FBC, ESR, CRP
Blood cultures
Arthrocentesis
If suspected gonococcal arthritis, what other samples need to be taken?
Urethral, rectal + throat swabs
Septic arthritis: when should IV abx be started?
After joint aspiration
Septic arthritis: how long should abx be given for?
2 weeks IV PLUS 2 weeks oral
Septic arthritis: abx for
Staph A
MRSA
N gonorrhoea or gram neg bacilli
Staph A: fluclox
MRSA: vancomycin
N. gonorrhoea or gram neg bacilli: cefotaxime
Management of severe Septic arthritis if joint isn’t very accessible (e.g. hip)
Open washout
