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Question 2#

A 49-year-old woman with a 60-pack per year history of smoking presents to the emergency department (ED) with complaints of constant, worsening right foot pain and tingling in the toes for several hours. She denies a history of trauma. On examination, she is in moderate distress from pain and has a regular cardiac rhythm at a rate of 104 bpm. Her right lower extremity has a palpable femoral pulse and cool, pale foot with nonpalpable pedal pulses. There is a faint dorsalis pedis arterial signal with continuous-wave handheld Doppler evaluation. Strength is intact in the foot and toes, but she reports pain during examination.

What is the most appropriate next step?

a. Admit to the hospital; begin a heparin infusion and antiplatelet therapy. Obtain an urgent echocardiogram to identify the source of embolism
b. Obtain urgent ankle–brachial indices (ABIs) and pulse volume recordings to determine the severity of disease and begin aggressive risk-factor– modifying medical therapy
c. Admit to the hospital for an urgent diagnostic abdominal aortogram with runoff and potential endovascular revascularization
d. Admit to the hospital for pain control and obtain a lumbar magnetic resonance imaging to evaluate for lumbar canal stenosis and pseudoclaudication
e. Obtain ABIs at rest and with exercise to assess for lower extremity PAD and a venous plethysmography of the lower extremities with exercise to evaluate for venous claudication

Correct Answer is C

Comment:

Admit to the hospital for an urgent diagnostic abdominal aortogram with runoff and potential endovascular revascularization. The patient described is suffering from acute critical limb ischemia. The hallmarks of acute limb ischemia are the five “P’s”, which are suggestive of impending tissue necrosis. They are pain, paralysis, paresthesia, pulseless, and pallor and some add poikilothermia (coldness) for a sixth “P.” Our patient exhibits all but paralysis. Based on the Society for Vascular Surgery/International Society for Cardiovascular Surgery classification scheme for clinical categories of acute limb ischemia, her limb is marginally to intermediately threatened. Acute limb ischemia requires prompt diagnosis and intervention to avoid limb loss and life-threatening systemic illness resulting from tissue gangrene.

Reference:

Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease). Circulation. 2006;21(113):e525–e557.