Pt w/ atraumatic leg pain Flashcards
What are the symptoms of acute limb ischaemia?
What is the difference in symptoms between embolus and thrombus?
Perishingly cold Paralysed Pale Parasthesia (tingling) Painful Pulseless
Embolus
- lodged in vessel with no previous collateral development
- quicker onset and more severe presentation
- normal pulses in contralateral limb
Thrombotic (chronic)
- slower onset and less sever presentation (good collaterals)
- absent pulses in contralateral limb)
What are the leading causes of acute limb ischaemia IN TRAUMA?
Compartment syndrome and crush injuries
What are the leading causes of acute limb ischaemia in the absence of trauma?
Arterial thromboembolism
-AF/valve disease/prosthetic valves/post MI
Arterial thrombus
-aneurysm/atherosclerosis
Venous thrombosis
-hypercoag states (pregnancy/cancer)
**always ask about other embolic/thrombotic events in the hx
What are some risk factors for acute limb ischaemia?
What are complications of acute limb ischaemia?
Smoking, HTN, hypercholesterolaemia, diabetes
Complications acute limb ischaemia -rhabdomyolysis -renal failure -amputation) (why you do an urgent embolectomy within 4-6 hours)
Investigations for acute limb ischaemia
PHYSICAL EXAMINATION:
- Feel for temperature, palpate all pulses (dorsalis pedis, posterior tibialis and popliteal) - consider doppler if can’t find
- BLOODS: FBC, Us+Es, CK, Coag screen, ABG, urinalysis (myoglobinuria-muscle damage/rhabdomyolysis)
- CT angiography
- Look for sources of emboli (arrhythmias, murmurs, valve sounds etc.) ECG and cardio USS
Management of acute limb ischaemia
Management of acute limb ischaemia
ITS AN EMERGENCY
-Pain relief - IV opioid
-Correct hypovolaemia IV fluids
-URGENT SURGICAL REVASCULARSATION within 4-6 hrs
-embolectomy (remove clot Fogarty catheter)
-angioplasty (balloon)
-bypass (chronic)
-Or medical anticoagulation (weigh up bleeding risk) with tissue plasminogen activator tPA (local arterial catheter)
- After surgery/tPA they will require heparin
- look for CAUSE of EMBOLI
Presenting features of cellulitis
Cellulitis (dermis , lymphatics and subcut fat)
- Red, hot, swollen, painful leg unilaterally
- deep
- may be a circumscribed area or may be whole leg
- systemic symptoms (fever and lymphadenopathy)
- might be associated with some kind of trauma (break in skin) - but can be spontaneous
Erysipelas is just superficial layers (just dermis and lymphatics) and with clearer margins
What is the most common causative organism of cellulitis?
Risk factors?
CELLULITIS
- group A strep (streptococcus pyogenes (two-thirds of cases)
- Staphylococcus aureus (one third)
- Can also be caused by anaerobic organisms e.g. clostridium perfringens - a sign of this is crepitus(gas)
RF: diabetes/immunocompromised/steroid use/obesity/alcoholics/foreign body in wound/heamatoma
Investigations for cellulitis
Investigations for cellulitis
- Often a clinical diagnosis but always examine the leg for the extent of rubor, tumour and dolor (consider marking it to track progress)
- Take swabs of any wounds
- Really important to FEEL FOR PULSES and check the neurovascular system is in tact
BE AWARE OF SEPSIS
Management of cellulitis
CONSIDER ADMISSION IF:
- patient has fever >38, is systemically unwell, has regional lymphadenopathy or the cellulitis is extensive
ABX for 7 days (admit for IV if severe)
- FLUCLOXACILLIN
- Erythromycin/clarithromycin if penicillin allergic
- Co-amoxiclav in facial cellulitis
MONITOR FOR SEPSIS
Presentation of DVT
Signs?
Presentation of DVT
- Red, hot, painful, tender, swollen calf or thigh
- dilated superficial vessels
UNILATERAL
Signs • Tachycardia • Hypoxia • Tachypnoea • Breathlessness
Causes and risk factors of DVT:
Causes and risk factors of DVT:
- have you been diagnosed with cancer?
- have you ever had clot in your lungs or legs?
- have you been immobile recently?
- have you been in hospital recently?
- have you had recent surgery?
- have you been pregnant recently?
- have you been on any long haul flights?
- has anyone in family had clots in lungs or legs?
PMH
- cancer
- thrombophillia (condition that affects your blood clotting)
DH
- IVDU
- oestrogen?
Relevant investigations for DVT
Investigations for DVT
- Thorough examination of the limb (collateral veins, pitting oedema)
- Measure the calf size (measure 10cm down from tibial tuberosity, if >3cm larger then confirmed swelling)
- BLOODS: FBC/UsEs/CRP/glucose
- WELLS SCORE
Management for DVT
Management for DVT
- Monitor obs (PE risk)
- If unprovoked-look for potential malignancy (full blood count, serum calcium, and liver function tests)
- compression stockings
If WELLS 3+ then DVT is LIKELY
- refer for USS within 4 hours
- if it can’t be done within 4 hours then do D DIMER and give 24 hour dose LMWH depending on trust guidelines in meantime (dalteparin, enoxaparin or tinzaparin).
- And do USS within 24 hours instead
WELLS <3
- do a D dimer
- if positive then refer to USS within 4 hours (if 4hrs is not possible do within 24 hours and give 24 hour dose LMWH depending on trust guidelines in meantime (dalteparin, enoxaparin or tinzaparin)
- if negative consider alternative diagnosis
If pregnant or IVDU - always USS
Presentation of gout
Mainly PAIN
- usually in the first MTPJ (big toe) but can be anywhere (other common site is knee)
- rapid onset
- warm, red, swollen, shiny skin
- lasts 1-2 weeks then resolves
ATRAUMATIC PAIN OVER SINGLE JOINT WITH NO OTHER SYMPTOMS - consider gout
What is gout?
Risk factors for gout?
- Gout is a disorder of purine metabolism characterised by
- Raised uric acid level in blood
- These URATE CRYSTALS precipitate in the joint space.
RF: Excess urate production - Diet high in purines (red meat, alcohol, seafood) -lymphoproliferative disorders -tumour lysis syndrome (chemotherapy)
Reduced urate excretion
- Age
- Drugs e.g. Diuretics
- Renal failure
- Hypertension
- Dehydration
Investigations for gout and what would you find?
Gout investigations
BEDSIDE
-examine joint and ASPIRATE
•Pink Needle shaped with Negative birefringence under polarised light
BLOODS
- serum urate (may be normal)
- FBC (raised CRP)
- think about septic (cultures)
IMAGING
- XRAY DIAGNOSTIC, only shows soft tissue swelling at first but might show RAT BITE lesions
- USS may show double contour sign
Management for gout
-DURING AN ACUTE EXACERBATION:
‘RICE’ and NSAIDS:
- Diclofenac works well (COLCHICINE or oral/IM steroids if renal failure)
-Then maintenance therapy of ALLOPURINOL (xanthine-oxidase inhibitor)
>don’t start in acute flare
>always start with NSAIDS cover as might cause flare
>if already started, continue during a acute flare
What should always be a differential diagnosis in gout
Septic arthritis (MONOARHTOPATHY)
Clinical presentation of septic arthritis
Presentation of septic arthritis
- Very painful joint (knee most common> hip >ankle). normally mono (multiple suggests IVDU)
- Swollen, red, hot
- ↓Range of movement – STIFF (usually held in slight flexion for comfort)
- Systemic: fevers/rigors/vomitting/heamodynamically unstable
What are the 3 mechanisms of infection for septic arthritis?
What are some risk factors for septic arthritis?
3 mechanisms of infection:
1) Adjacent osteomyelitis
2) Haematogenous spread of infection elsewhere (common)
3) Puncture wound
Septic arthritis can be spontaneous, however risk factors include:
- recent trauma or surgery
- immunosuppression (steroids)
- diabetes
- prosthetic joints (CONS-staph epidermis)
- IVDU (heamatogrnous spread)
- rheumatoid arthritis
What organisms commonly cause septic arthritis? (most common?)
What organism causes septic arthritis in prosthetic joint?
Organisms in septic arthritis
• Staphylococcus aureus - 70%
• Streptococci
• Neisseria gonorrhoea(sexually active young patient)
• E Coli
• HiB
Septic arthritis in prosthetic joints - coagulase negative staphylococci e.g. staph epidermis
What investigations should you do for suspected septic arthritis?
Bedside
- joint aspiration (yellow, purulent, WCC+++)
- send for MSC (culture), gram stain and crystallography START IV AB IMMEDIATELY AFTER
Bloods
- FBC
- Blood cultures (narrow AB according to results)
- CRP, ESR
- Us Es
- LFTs
Imaging
- X-Ray - may be normal initially or show soft tissue swellingand effusion (widened joint space)
- Later - features of bone destruction and joint space narrowing
- Can also do USS to look for effusion
- Bone scan if multiple sites + too unwell to localise pain
What is the management of septic arthritis? (4)
What medical treatment if allergies?
What medical treatment if MRSA?
What medical treatment if gonococcal
What medical treatment if E.Coli?
- Medical
IV ANTIBIOTICS, then oral for 4-6 weeks
FLUCLOXACILLIN
If penicillin allergic - clindamycin
If MRSA suspected, vancomycin(or teicoplanin)
If gonococcal/E.Coli - cefotaxime(or ceftriaxone)
- Surgical
- Refer urgently to the orthopaedic team for surgical drainage, irrigation + debridement
- Remove prosthetic joint if they have - Splint
- joint immobilised in functional position to reduce pain + inflammation → later mobilised (to prevent permanent deformity - Physiotherapy
– to ↓joint stiffness
