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ACC > Pt w/ atraumatic leg pain > Flashcards

Pt w/ atraumatic leg pain Flashcards

1
Q

What are the symptoms of acute limb ischaemia?

What is the difference in symptoms between embolus and thrombus?

A 
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)
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2
Q

What are the leading causes of acute limb ischaemia IN TRAUMA?

A

Compartment syndrome and crush injuries

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3
Q

What are the leading causes of acute limb ischaemia in the absence of trauma?

A

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

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4
Q

What are some risk factors for acute limb ischaemia?

What are complications of acute limb ischaemia?

A

Smoking, HTN, hypercholesterolaemia, diabetes

Complications acute limb ischaemia
-rhabdomyolysis
-renal failure
-amputation)  
(why you do an urgent embolectomy within 4-6 hours)
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5
Q

Investigations for acute limb ischaemia

A

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
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6
Q

Management of acute limb ischaemia

A

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
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7
Q

Presenting features of cellulitis

A

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

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8
Q

What is the most common causative organism of cellulitis?

Risk factors?

A

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

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9
Q

Investigations for cellulitis

A

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

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10
Q

Management of cellulitis

A

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

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11
Q

Presentation of DVT

Signs?

A

Presentation of DVT

  • Red, hot, painful, tender, swollen calf or thigh
  • dilated superficial vessels

UNILATERAL

Signs
• Tachycardia
• Hypoxia
• Tachypnoea
• Breathlessness
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12
Q

Causes and risk factors of DVT:

A

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?
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13
Q

Relevant investigations for DVT

A

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
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14
Q

Management for DVT

A

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

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15
Q

Presentation of gout

A

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

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16
Q

What is gout?

Risk factors for gout?

A
  • 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
17
Q

Investigations for gout and what would you find?

A

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
18
Q

Management for gout

A

-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

19
Q

What should always be a differential diagnosis in gout

A

Septic arthritis (MONOARHTOPATHY)

20
Q

Clinical presentation of septic arthritis

A

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
21
Q

What are the 3 mechanisms of infection for septic arthritis?

What are some risk factors for septic arthritis?

A

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
22
Q

What organisms commonly cause septic arthritis? (most common?)

What organism causes septic arthritis in prosthetic joint?

A

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

23
Q

What investigations should you do for suspected septic arthritis?

A

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
24
Q

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?

A
  1. 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)

  1. Surgical
    - Refer urgently to the orthopaedic team for surgical drainage, irrigation + debridement
    - Remove prosthetic joint if they have
  2. Splint
    - joint immobilised in functional position to reduce pain + inflammation → later mobilised (to prevent permanent deformity
  3. Physiotherapy
    – to ↓joint stiffness
25
Q

Possible complications of TREATING acute ischaemic limb?

A

-postoperative reperfussion injury and compartment syndrome

26
Q

What are complications of orbital cellulitis?

A

Complications of orbital cellulitis

  • blindness
  • cavernous sinus thrombosis
  • meningitis
27
Q

Wells score

A

1 POINT FOR EACH OF THE FOLLOWING

  • Active cancer (treatment ongoing, within the last 6 months, or palliative).
  • Paralysis, paresis, or recent plaster immobilization of the legs.
  • Recently bedridden for 3 days or more, or major surgery within the last 12 weeks requiring general or regional anaesthesia.
  • Localized tenderness along the distribution of the deep venous system (such as the back of the calf).
  • Entire leg is swollen.
  • Calf swelling by more than 3 cm compared with the asymptomatic leg.
  • Pitting oedema confined to the symptomatic leg.
  • Collateral superficial veins (non-varicose).
  • Previously documented DVT.

Subtract 2 POINTS if an alternative cause is considered at least as likely as DVT.

28
Q

LMWH Mechanism of Action

A

Heparins bind to antithrombin which accelerates inhibition of Factor Xa

29
Q

What can be seen in pseudo gout?

A

Rhomboid shaped PPPyrophosphate dehydrate crystals in PPPseudogout showing PPPositive birefringence

30
Q

Gout vs Pseudogout? (substance, x ray findings, bifringment, shape, colour, treatment)

A

Gout vs pseudo gout

  • uric crystals vs calcium pyrophosphate crystals
  • rat bite vs chondrocalcitosis (calcium in cartalidge)
  • negitive brifringment vs positive bifringment
  • needles vs rhomboid
  • pink vs purple
  • BOTH NSAIDS
31
Q

Risk factors for psuedogout?

A

Psuedogout

  • Advanced age
  • Injury or previous joint surgery
  • OA
  • Hyperparathyroidism
  • Hypothyroidism
  • Haemochromatosis
32
Q

What is the treatment for DVT (what if they have renal impairment?)

A

Apixaban
If unsuitable give LMWH (unfractioned heparin if renal impairment)

1st line: apixaban or rivaroxaban

or LMWH for at least 5 days followed by dabigatran or edoxaban
or LMWH concurrently with warfarin for 5 days.

33
Q

What is post-thrombotic syndrome?

A
  • It develops after trauma to deep veins and their valves due to chronic venous hypertension
  • It is a common complication of DVT.
  • You get pain, swelling, hyperpigmentation, dermatitis, ulcers and gangrene
34
Q

What do you do if you get a negetive USS for DVT?

A

Do a D-dimer test (see below) if the scan result is negative (just in case)

ACC (23 decks)

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