Acute limb ischaemia

Diagnosis: The embolic acute limb ischaemia — the atrial fibrillation (the not-anticoagulated, the commonest embolic source), the sudden onset (the 90 minutes), the no history of the claudication, and the six Ps (the pain, the pallor, the coldness, the absent pulses, the reduced sensation, the toe dorsiflexion weakness). The motor deficit (the toe dorsiflexion weakness) places this at the Rutherford IIb — the immediately threatened — the salvageable only with the immediate revascularisation.^[1]

Assessment: ABCDE, the analgesia. The hand-held Doppler and the ankle-brachial pressure index (the confirm and the quantification). The bloods (the full blood count, the coagulation, the urea and electrolytes, the group and save), the ECG (the atrial fibrillation), the echocardiogram for the source (the delayed). The NO CT angiogram — this is the immediately threatened limb (the IIb), and it goes straight to the theatre.^[1]

Management:

1. The immediate vascular surgery referral — the cornerstone. The theatre.
2. The IV unfractionated heparin (the therapeutic bolus and the infusion) — prevents propagation, buys time.
3. The surgical embolectomy (the Fogarty catheter) — the standard for the embolic.
4. The prophylactic fasciotomy after the revascularisation (the compartment syndrome of the reperfusion).
5. The anticoagulation of the atrial fibrillation and the investigation of the source.

The disposition: The theatre, then the vascular ward or the intensive care for the monitoring of the reperfusion complications (the hyperkalaemia, the myoglobinuria, the renal failure).^[1]

The time-critical principle: The six-hour window — the irreversible nerve and muscle damage. The motor deficit (the IIb) is the emergency.^[1]