Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

Arterial Embolus 159

➣Bleeding at puncture site

➣Intracranial bleeding

➣Systemic fibrinolysis

■Contraindications (Absolute)

➣Severe ischemia with neuromuscular changes requiring imme-

diate revascularization

➣Contraindications (Relative)

➣Bleeding or risk of bleeding (recent surgery or catheterization)

Expectant Therapy (Amputation)

■Reserved for clearly nonsalvagable limbs (muscle rigor, extensive

gangrene)

■Usually requires above-knee amputation

■Little chance of ambulation afterwards

follow-up

During Treatment

■Surgical Embolectomy

■Postoperative long-term anticoagulation (heparin and then

coumadin)

■Echocardiogram and TEE to evaluate source of embolus

■Study aorta (Angio, MRA) if cardiac w/u negative for thrombus

■Thrombolytic therapy

■Serial angiograms and neurological exams to assess progression of

lytic therapy

■Serial fibrinogen levels to assess systemic fibrinolysis

Routine

■Long-term anticoagulation reduces recurrent emboli

complications and prognosis

Complications

■Hyperkelemia from reperfusion

➣Vent first 500cc of venous blood to prevent Compartment syn-

drome

➣Common if ischemia > 4 hrs

➣Not seen until 12–24 hrs after reperfusion

➣First sign is pain on passive motion of foot or decreased sensation

between 1st/2nd toes

➣Compartment pressures can be measured if exam is unreliable

➣Prevent with prophyactic fasciotomy