100 Cases in Surgery
ANSWER 48 This is an acutely ischemic limb secondary to arterial embolism (arrow in Fig. 48.3).
Figure 48.3 Angiogram showing an occlusion of the brachial artery.
The embolus is likely to have originated from the left atrium as the patient has atrial fibrillation (shown on the ECG). Aetiologies include: • • • • •
cardiac arrhythmias: commonly atrial fibrillation aneurysmal disease procoagulant state caused by underlying malignancy thrombophilias atrial myxomas.
Investigations aim to determine the aetiology of the embolism and to prepare the patient for theatre: • • • • •
full blood count (polycythaemia) clotting group and save ECG (arrhythmias) chest X-ray (underlying malignancy).
The patient should be given heparin and resuscitated with intravenous fluids and analgesia. Loss of sensation and paralysis in the affected limb (signs of advanced ischaemia) are indications for urgent embolectomy. A postoperative echocardiogram is arranged if preoperative investigations do not reveal an obvious cause for the embolism. This investigation can detect cardiac thrombus or an atrial myxoma. KEY POINTS Signs and symptoms of acute limb ischaemia – six Ps: • pain • pulseless • pallor • paraesthesia • perishingly cold • paralysis. 112