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Acute Limb Ischemia

A cold pulseless limb is a clock — and sometimes a dissected aorta.

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Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Exam first: pulses, Doppler, comparison with the other limb, and a motor/sensory map.
  2. Chest or back pain with a pulse deficit is dissection until CTA says otherwise — do not anticoagulate blindly.
  3. Classic ALI: unfractionated heparin and an immediate vascular call; imaging must not delay a clearly threatened limb.

2 · Escalate now if

  • Pulseless, pale, or paralyzed limb
  • Chest or back pain with a pulse deficit
  • Pain on passive stretch after trauma or reperfusion
  • Crepitus, bullae, or shock with a soft-tissue source
  • Cyanotic swollen limb (phlegmasia)
  • Rest pain in a vasculopath with tissue loss

3 · Immediate workup

  • ECG (AF, ischemia); bilateral arm BP
  • Handheld Doppler; POCUS for AAA and dissection flap if trained
  • Glucose, lactate

4 · Don’t miss

  • Embolic or thrombotic acute limb ischemia
    Sudden pain, pallor, pulselessness — Rutherford threatened limb needs revascularization now. Heparin unless dissection is the leading diagnosis.
  • Aortic dissection into a limb
    Chest/back pain + pulse deficit or a cold arm/leg — CTA aorta first; anticoagulating this as a simple embolus can be lethal.
  • Phlegmasia cerulea dolens / massive DVT
    Cyanotic swollen limb, often malignant or post-op — anticoagulation ± thrombolysis/thrombectomy; watch for venous gangrene.
  • Compartment syndrome
    Pain on passive stretch after trauma, crush, or reperfusion — compartment pressures support but do not override clinical diagnosis; fasciotomy.
  • Necrotizing soft-tissue infection
    Pain out of proportion, rapid spread, crepitus, or shock — surgery now.

5 · Disposition lane

Admit (vascular)

Viable but symptomatic ischemia, phlegmasia on anticoagulation, post-cath blue toe, infection needing IV therapy.

Emergency revascularization / OR / ICU

Threatened or irreversible ALI, dissection, compartment syndrome, necrotizing infection.