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