Inadequacies of Physical Examination in Patients with Acute Lower Limb Ischemia Are Associated with Dreadful Consequences

Andrea Kulezic,Martin Macek,Stefan Acosta

doi:10.1016/j.avsg.2021.10.067

Andrea Kulezic, Martin Macek + Show 1 more

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https://doi.org/10.1016/j.avsg.2021.10.067

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Abstract

Acute lower limb ischemia (ALI) is limb and life-threatening. The aim of this study was to explore the association between adherence to guidelines on clinical diagnosis of ALI and outcome at 1 year. The hypothesis was that that better examination was associated with favorable outcome in ALI patients. Retrospective cohort study between 2015 and 2018. In-hospital, operation, radiological and autopsy registries captured 161 citizens of Malmö with ALI. The initial bedside evaluation was performed by an emergency physician. Scoring was based on evaluation of the 6 "Ps" and 1 point was given for pain, pallor, pulselessness, perishing cold, paresthesia, paralysis or ankle-brachial pressure index (ABI). The performance was scored (range 0-7), and a score ≥5 was defined as a satisfactory vascular leg status. A multivariate logistic regression was performed to adjust for confounders and expressed in Odds Ratios (OR) with 95% confidence intervals (CI). A satisfactory first clinical examination was performed in 55.3% of the patients. Measurement of ABI (OR 0.25, 95% CI 0.11-0.55), performing complete pulse status (OR 0.41, 95% CI 0.20-0.85), evaluating paralysis (OR 0.43, 95% CI 0.20-0.89), and a bedside score ≥5 points (OR 0.48, 95% CI 0.23-0.97) were independently associated with reduced risk of major amputation/mortality at 1-year follow up. Quality of initial bedside evaluation in patients with ALI was unsatisfactory to a large extent and better clinical examinations were associated with favorable outcome at 1 year. Skills in clinical diagnostics in ALI needs to be much improved.

Highlights

The six “Ps” are signs of acute lower limb ischemia (ALI) and comprises pain, pallor, pulselessness, perishing cold, paraesthesia and paralysis
The median symptom duration of those undergoing operative revascularization (n=88) was 96 hours (IQR 24 – 282) from onset of symptoms to start of operation and 24 hours (IQR 9 – 120) from onset of symptoms to admission to hospital in those managed without operative revascularization (n= 71)
Bedside evaluation associated with major amputation/mortality at 1 year After adjustment for confounders, measuring ankle-brachial pressure index (ABI), performing complete pulse status, evaluating paralysis, and a bedside score ≥5 points were associated with reduced risk of major amputation/mortality at 1-year follow up (Table 2)

Summary

Introduction

The six “Ps” are signs of acute lower limb ischemia (ALI) and comprises pain, pallor, pulselessness, perishing cold (poikilothermia), paraesthesia and paralysis. They are good diagnostic tools for physicians in the emergency department (ED) to conduct a primary evaluation of suspected ALI. In patients presenting too late, after failed revascularization attempts or when revascularization is not considered an option due to advanced age, high comorbidity burden and/or extensive occlusive lesions in the arterial circulation of the lower limb(s), amputation is a definitive treatment option [2]. Palliative treatment is considered in patients that neither benefit from revascularization, amputation, conservative anticoagulant therapy or that refuse revascularization surgery [3]

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