Acute Limb ischemia in elderly

[Karim Brohi]

Saad

The tPA will not precipitate aneurysm rupture, but the complications you
describe are typical of thrombolysis (as well as compartment syndrome,
haemorrhagic stroke etc). Our use of thrombolysis is very rare now.  The
patient should be made palliative.

Karim

PS.  This is not really trauma.  There is a vascular surgery forum which is
more appropriate,
http://vasc-surgery.com/ 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of saad shebrain
Sent: 02 December 2007 18:43
To: trauma-list at trauma.org
Subject: Re: Acute Limb ischemia in elderly

Than you all,
  All options you give are more than reasonable.
   
  Now, discussion with family and pt they preferred to proceed with
throbolytics with risk of bleeding.
   
  Angio done, Complete Graft occlusion, with some collaterals for the
profunda.
  tPA started, overnight, Fibrinogen drop to 118, 68, tPA was D/Cd per IR at
2 AM, although some said you could decrease the dose to quarter/h, in AM H/H
12/35, fibrinogen 60.
  6AM pt lost the pulse in Rt DP,PT.
   
  Pt was taken to IR, the graft Still completely occluded. MECHANICAL
thrombectomy cleared the clot, and flow distally to ankle (PT was achived),
on the Rt leg, the Pop at trifurcation is out.
   
  Decision was stop and take sheth out and start heparin drip once pt
returned to ICU.
  in IR suite, BP was 110-140/50-70s, HR 110-140s A-fib
   
  Rt groin hematoma was noticed after removing the sheath, 30 min pressure
applied.
   
  In ICU hematoma was larger, and H/H wa 6/18, pH 6.98, pt desat, intubated,
became hypotensive, multiple CPRs and drugs. she was transfused and prepared
for a trip to OR for groin X-ploration. she required 2 pressors
  ECHO; 30% EF, severe MR.
   
  abdomen was distended.
   
  in OR, the puncture in her CFA, was not enogh to explain her drop in H/H.
apprx. 500 ml blood in the thigh. no concern about significan
retroperitoneal bleeding from the CFA puncture site.
   
  on return to ICU pt developed bradycardia and cardiac arrest.
   
  Q:
  1. Could this pt develop severe DIC with clot to Right (intact) leg vs.
clott triggered by the sheath.
  2. if we suspect AAA rupture, is there any role for US at bed side, if not
and pt is unstable at this point, is DPL going to help.
  3. could the tPA quickly accelerate her AAA rupture.
  4. anything to be done differently in this patient.
   
  Thankx
   
  SS
   
   




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