Management and Treatment

Management Before Treatment

Viable Leg

If the leg is viable the patient is admitted for observation. A checklist of what needs to be done in the emergency department follows below:

1.Place an intravenous (IV) line.

2. Start infusion of fluids. Because dehydration is often a part of the pathogenic process, Ringer’s acetate is usually preferred. Dextran is another option that also is beneficial for blood rheology.

3. Draw blood for hemoglobin and hematocrit, prothrombin time, partial thromboplastin time, complete blood count, creatinine, blood urea nitrogen, fibrinogen, and antithrombin. Consider the need to type and cross-match blood.

4.Order an electrocardiogram (ECG).

5.Administer analgesics according to pain intensity. Opiates are usually required (morphine 2.5–10mg IV).

6.Consider heparinization, especially if only Ringer’s acetate is given. Heparin treatment should be postponed until after surgery if epidural anesthesia is likely.

Repeated assessments of the patient’s clinical status are mandatory in the intensive care unit and when the patient has been moved to the ward. The time interval depends on the severity of ischemia and the medical history. This examination includes evaluating skin color, sensibility, and motor function as well as asking the patient about pain intensity.

Dextran is administered throughout the observation period. The risk for deterioration of heart failure due to dextran treatment is substantial and for patients at risk the volume load must be related to the treatment’s expected possible benefits. For such patients it is wise to reduce the normal dose of 500ml in 12h to 250ml. Another option is to prolong the infusion time to 24h.

Heparin only or in combination with dextran is recommended when patients do have an embolic source or a coagulation disorder. There are two ways to administer heparin. The first is the standard method, consisting of a bolus dose of 5,000 units IV followed by infusion of heparin solution (100units/ml) with a drop counter. The dose at the start of infusion should be 500 units of heparin per kilogram of body weight per 24h. The dose is then adjusted according to activated partial thromboplastin time (APTT) values obtained every 4h. The APTT value should be 2–2.5 times the baseline value.

Low molecular weight heparin administered subcutaneously twice daily is the other option. A common dose is 10,000 units/day but it should be adjusted according to the patient’s weight.

It is important to optimize cardiac and pulmonary function while monitoring the patient. Hypoxemia, anemia, arrhythmia, and hypotension worsen ischemia and should be abolished if possible. A cardiology consult is often needed.

The above-mentioned treatment regime of rehydration, anticoagulation, and optimization of cardiopulmonary function often improves the ischemic leg substantially. Frequently this is enough to sufficiently restore perfusion in the viable ischemic leg, and no other treatments are needed. If no improvement occurs, angiography can be performed during the daytime, followed by thrombolysis, PTA, or vascular reconstruction.

Date: 2014-12-29; view: 1070