PERIPHERAL VASCULAR DISEASE

Claudication

History

•  Ischemic muscle pain reproducible w/ exertion, improves w/ rest

•  Pts often place legs in dependent position to improve flow

•  1–2% have chronic critical limb ischemia: Pain at rest, nonhealing ulcers, dry gangrene

Findings: May have nl exam at rest w/ or w/o ↓ peripheral pulses

Evaluation

•  ABI <0.9 is diagnostic of PVD (sens & spec)

•  Careful pulse exam, w/ Doppler if difficult to palpate

•  Look for signs of critical ischemia (rest pain, nonhealing ulcers)

Management: If concern for critical ischemia or acute dz, vascular surgery consult

Disposition

•  Admit acute dz

•  D/c home if chronic w/ vascular surgery f/u, strict return instructions

Acute Extremity Arterial Occlusion

History

•  Known PVD +/or RFs (HTN, tobacco, known CAD, AF)

•  Abrupt onset of pain w/ distal paresthesias

•  Late (concerning findings): Pain, pallor, paresthesia, pulselessness

Findings

•  Cold, mottled extremity, ↓ pulse, motor weakness, ± bruit

•  Tenderness to palpation out of proportion of exam or ↓ sensation

Evaluation

•  Bedside Doppler of all pulses, including unaffected extremities; ABI

•  U/S can demonstrate level of occlusion

•  CTA or angiography

•  ECG for arrhythmia, may need echo to look for embolic source

Treatment

•  Immediate vascular surgery consultation for possible embolectomy

•  Anticoagulation (discuss w/ vascular): Heparin 18 U/kg/h IV w/o bolus

Disposition

•  Transfer to facility w/ vascular surgery capability if none available

Pearl

•  Ischemic tissue death starts by 4 h; sooner in pts w/ chronic arterial insufficiency

TRAUMA

Compartment Syndrome

History

•  Can occur in any closed fascial space, most commonly in distal lower extremity (calf)

•  H/o trauma (esp crush), burns, rhabdomyolysis, tight cast/dressing, hemorrhage (anticoagulants, coagulopathy), postischemic swelling, snakebites, IVDU

Findings

•  Pain out of proportion to exam, pain w/ passive stretch of muscles that run through compartment (see the table below), paresthesias, pallor of the extremity, taut or rigid compartment. LATE: Decreased pulse, sensory/motor deficits.

Evaluation

•  Measure compartment pressures: nl <8 mmHg; emergent fasciotomy if >30 mmHg

•  Stryker instrument: Enter each compartment perpendicular to the skin

•  A-line manometer: Attach 18G needle to A-line manometer; check that the compartment pressure being measured is at the same height as the manometer transducer

Treatment

•  Immediate orthopedic/surgical consult for fasciotomy

Disposition

•  Admit to ortho for serial manometry & neurovascular checks if compartment pressures <30 mmHg but evolving compartment syndrome suspected

Pearls

•  nl compartment pressure does not r/o compartment syndrome; clinical Dx

•  6% incidence open tibia fx; 1% in closed tibia fx; 30% w/ arterial injury; 14% w/ venous

LOWER BACK PAIN

Approach

•  Careful hx: Anatomic distribution, unilateral vs. bilateral, acute vs. chronic, fever, abdominal pain, groin pain, syncope h/o trauma; worse at rest or at night; incontinence?

•  Physical exam w/ thorough neurologic exam, straight leg raise, pulses, rectal tone, gait

•  Always check urine pregnancy test in females of childbearing age

•  X-rays not routinely indicated: Use for red flags above, abnl exam, point tenderness

•  Most require only analgesia & f/u but always consider life- & limb-threatening conditions

TRAUMA

Acute Lumbosacral Strain

History

•  Usually h/o precipitating event: Twisting, lifting, new workout. Acute/subacute onset.

•  Should have no fever or radicular sxs

Findings: Paravertebral muscle spasm & tenderness, nl neuro exam

Evaluation: No indication for imaging acutely

Treatment

•  NSAIDs; if severe, short course opioids or benzodiazepines; early activity (no bed rest)

•  Muscle relaxants of no proven value, many side effects (anticholinergic)

Disposition: D/c home w/ PCP f/u, strict return instructions

Pearl: Lumbar strain is the #1 cause of LBP in ED but Dx of exclusion

Vertebral Compression Fracture

History: Acute-onset LBP usually in elderly pts w/ osteopenia, smoking, on steroids

Findings: Focal tender area on spine, usually no neuro findings

Evaluation: Plain film of affected thoracic, lumbar, or sacral spine

Treatment

•  Usually stable fractures; analgesia ± brace for comfort

•  Consult ortho or spine for >50% compression or multiple fractures

Disposition: Admit for intractable pain, any neuro findings, >50% compression, multiple fractures

Pearl: Look for neoplastic cause if no other RFs or hx, esp in elderly

NEUROLOGIC

Cauda Equina Syndrome

Definition: Large central disk herniation of distal spinal cord – neurosurgical emergency

History

•  Severe LBP shooting down 1 or both legs & neuro sxs: Saddle paresthesias, urinary retention w/ overflow incontinence, loss of bowel control or sexual Dysfxn; pts w/ recent trauma or cancer w/ possible mets

Findings: ↓ rectal tone, urinary retention, saddle anesthesia, areflexia, weakness

Evaluation

•  MRI is imaging test of choice

•  Postvoid residual is the most sens initial finding

Management: Emergent Neurosurgery consult, admit

Lumbar Spinal Stenosis

Definition: Narrowing of lumbar spinal canal from degeneration, facet arthritis, or subluxation

History: 40+ y/o, bilateral low back pain, pseudoclaudication (pain w/ walking), age >40, improves w/ rest & flexion of back (walk hunched over to keep back flexed)

Findings: nl exam, nl SLR, pain w/ back extension

Evaluation: Emergent imaging not needed if nl neuro exam; CT, MRI are diagnostic

Treatment: Pain mgmt w/ NSAIDs; hip flexor & abdominal exercises; surgery if severe

Disposition: Close f/u w/ PCP

Herniated Disc

History

•  30–40 y/o, h/o waxing/waning back pain shooting down leg (past knee) ± paresthesias

•  Exacerbated by leaning forward, coughing, sneezing, & straining (stretches nerve root)

Findings

•  See table below (L4–5 is most common)

•  SLR test correlates w/ nerve root irritation only if reproduced sxs extend below knee. Ipsilateral is sens, contralateral is spec.

Management:

•  Neuro intact: Analgesia, DC home. MRI or CT myelogram if no improvement in 4–6 wk.

•  Neuro deficits (or acute traumatic herniation): MRI to eval for cord involvement

Disposition: D/c if no cord findings; o/w need neurosurgery consult

Pearl: Sciatica is lumbar disc herniation impinging on sciatic nerve

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