Limb pain / swelling

Question 1

How should a DVT be diagnosed?

Answer 1

NB similar to PE
1. Measure leg circumference 10cm below tibial tuberosity (>3cm = likely DVT)
2. Well’s score (score >2 = likely DVT)
LIKELY DVT
-Refer for proximal leg vein USS within 4 hours
-If not possible, do D-dimer and give 24h dose of anticoagulant and arrange for scan in 24h
UNLIKELY DVT
-Do D-dimer - if positive do as above

Question 2

How should a DVT be managed?

Answer 2

-Apixaban / rivaroxaban
-If above is unsuitable, LMWH, followed by dabigatran / edoxaban after 5 days // vit K antagonist
-Carry out FBC, U+Es, PT and APTT
-Continue for at least 3 months

Question 3

What is the Eron classification system for cellulitis?

Answer 3

Class I = no signs of systemic toxicity and the patient has no uncontrolled comorbidities
Class II = patient is either systemically unwell OR well with comorbidities
Class III = patient is significantly unwell, eg acute confusion, tachycardia, tachypnoea, hypotension or unstable comorbidities that my interfere with treatment or limb is threatened due to vascular insufficiency
Class IV = patient is septic or has a severe life-threatening infection eg necrotising fasciitis

Question 4

What are the main investigations carried out for cellulitis?

Answer 4

-Swab for culture if there is an open wound
-WCC, ESR, CRP

Question 5

How is cellulitis managed?

Answer 5

-Class I + II = community
-Class III + IV / immunocompromised / very young / elderly = hospital (IVs)
-Flucloxacillin 500-1000mg QDS for 5-7 days
-If not suitable, clarithromycin / doxycycline
-If infection is near the eyes ie orbital cellulitis but can be treated in the community –> co-amoxiclav

Question 6

What are causes of acute limb ischaemia?

Answer 6

-Most have pre-existing CVD
-Thrombosis present in 40%, >80% are emboli from cardiac sources
-Graft / angioplasty occlusion

Question 7

What are the main features of an ischaemic limb?

Answer 7

• 6 P’s = pain, paraesthesia, pallor, pulseless, paralysis, perishingly cold
  -Hair loss, muscle wasting (chronic)
  -Mottling (irreversibility)
  -Critical limb ischaemia features:
  –Pain on rest (>2 weeks)
  –Ulceration
  –Gangrene
  –ABPI <0.5

Question 8

What investigations would you carry out for someone with an ischaemic limb?

Answer 8

-ECG, CXR
-U+Es, CK, FBC, clotting
-ABG, urinalysis
-Crossmatch (surgery)
-Cardiac / abdo USS for thrombosis in situ
-ABPI
–0.6-0.9 = claudication
–0.3-0.6 = rest pain
–<0.3 impending limb loss

Question 9

How would you manage an ischaemic limb?

Answer 9

-Surgery / angioplasty within 6 hours
-Anticoagulation with heparin
-Treat cause / manage CVD (statin)
-Beware of repercussion injury / compartment syndrome