อาการและอาการแสดง:
จะมาด้วยอาการอย่างใดอย่างหนึ่งใน "6 Ps" ได้แก่ pain, pallor, paralysis, pulselessness, paresthesias,
poikiothermia; ให้ประเมิน 3 อย่างได้แก่
- Localization (aorto-iliac-femoral-popliteal)
- Degree of ischemia
- Etiology (thrombosis, embolism)
ประเมิน degree
of ischemia โดยใช้ Rutherford criteria
Degree of ischemia
|
Sensory
loss
|
Muscle
weakness
|
Arterial
Doppler
|
Venous
Doppler
|
I Viable
|
None
|
None
|
Audible
|
Audible
|
IIa Marginal threatening
|
Toes
|
None
|
X
|
Audible
|
IIb Immediately threatening
|
>
Toes, rest pain
|
Mild-moderate
|
X
|
Audible
|
III Irreversible
|
Anesthesia
|
paralysis
|
X
|
X
|
ประเมินสาเหตุ
Emboli
|
Thrombosis
(> 80%)
|
|
|
สาเหตุอื่นๆ: catheterization complication, trash foot/blue toe syndrome (atheroemboli), vasculitis (RA, lupus, PAN), Raynaud’s disease, Takayasu’s arteritis, Thromboangiitis obliterans (Buerger’s disease), HIV arteritis, hypothenar hammer syndrome, popliteal artery entrapment, popliteal aneurysm, external iliac artery endofibrosis, local artery trauma, shock-related arterial ischemia, thoracic aortic dissection, intra-arterial drug injection, vasopressor
Investigation
- CBC, BUN, Cr,
electrolytes, glucose, CPK, lactate, cardiac enzyme, PT, aPTT, fibrinogen (ถ้าอาจให้
thrombolytic); ECG, CXR
- CT angiography
ของ
abdomen, pelvis, bilateral lower extremities (chest มักทำตอน
post-op)
- Ankle-brachial index (ABI) ในรายที่ตรวจ Doppler ได้ ถ้า < 0.4 แสดงว่ามี severe ischemia; **10% ของผู้ป่วยมี anatomic variation จะตรวจ Doppler ไม่ได้
Initial management of acute embolism
of lower extremities
- Consult vascular surgeon, cardiologist (medical risk assessment)
- UFH 80 U/kg IV bolus then IV drip 18 U/kg/h
- IVF, pain control, environment protection:
จาก
extreme temperature
Chronic obstructive arterial obstruction (> 2 สัปดาห์) ให้ aspirin 81-162 mg/d และ disease
modification ได้แก่ smoking cessation, exercise; ยาที่ใช้รักษาอาการ claudication ได้แก่ cilostazol,
phosphodiesterase inhibitor, pentoxifylline
Disposition: ใน chronic PAD stage I สามารถ D/C ได้ ให้ ASA 325 mg PO stat then 81 mg/d และนัด F/U vascular surgeon
Ref: Tintinalli ed8th, Up-to-Date
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