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The waiting game

Non-Covid clinical crises: Critical ischaemia of the foot/leg

Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available

Acute limb ischaemia is a history of less than two weeks and chronic is more than two weeks.

A history needs to include details on:

  • Timeline of symptoms
  • Medication
  • Anticoagulant use (check dose is appropriate)
  • Arterial disease
  • Smoking status
  • Cardiovascular disease
  • Diabetes

Six signs of acute limb ischaema within the two week period that warrant an immediate emergency referral to the on-call vascular team - including chronic symptoms that have deteriorated within the past two weeks - include:

  • Pale
  • Pulseless
  • Perishingly cold
  • Parasthesia
  • Paralysis
  • Painful (in the toes, potentially up to foot and the ball of the foot and normally at night.)

You do not need all six for diagnosis. The more established the acute problem is, the more likely you will get all six, especially the parathesia and paralysis later on. If you find some of these signs, that is a positive finding, so you will need to treat is as an urgent referral.

For chronic ischaemic limb:

  • Mild (no symptoms or a pain in the calf on long distances) can be managed with medication for risk factors and smoking cessation. Patients should already be on aspirin or clopidogrel to reduce the cardiovascular risk.
  • Intermediate (pain in the calf on standing or walking shorter distances that interferes with day to day activities) can be managed in the community during COVID-19 as with mild. After COVID-19 a routine referral can be made.
  • Severe (ischaemic rest pain or ulceration or gangrene, or both) needs an urgent referral to a vascular service within two weeks, ideally as an outpatient.

Mr Constantinos Kyriakides is a consultant vascular and endovascular surgeon, Barts Health NHS Trust

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