 All right, so we're going to discuss Vascular and I'll ask you questions first and then my colleague will ask you some more questions. Okay, is that fine? Now, have you ever managed a patient with a limb that comes in that is obviously necrotic and dead? Can you just run me through the causes of necrotic low limbs? So by definition necrosis refers to a tissue that is no longer viable. The causes for necrotic limbs can be classified into infective causes and then purely vascular non-infective or infective and non-infective. Going down the non-infective route, causes can be classified into thrombos and emboli. Under your emboli, there are different causes for your emboli so they can be from the, they can have cardiac source, they can have aneurysmal source. Okay, that's that limb done. In terms of your thrombus, they can be an existing thrombus that caused obstruction of the blood supply to the limb. It can be something that's propagating, moving on to your infectious causes. Infectious causes causing necrotic limb would really be your very severe infections like your neck fash rather than your superficial tissue infections. Now you mentioned obviously arterial causes, wouldn't you suggest that which is a vascular compromise, a blood supply compromise other than just thrombos and emboli, certainly there are other causes of blood not flowing to them causing a dead limb. Yes, you could have trauma. How would trauma need to a dead limb? So if you've got occlusion of your arterial supply, completed occlusion of your arterial supply secondary to trauma, you could result in a dead limb. From what mechanisms? Penetrating trauma, blood trauma could do it, so for example crush injuries, compartment syndrome. There's compartment syndrome, tell me a bit more about compartment syndrome leading to a dead limb. Is that sitting here a large percentage of patients that you left out of your causes then? Compatiment syndrome by definition refers to a condition in which the pressures within a particular osteo-fascial compartment exceed the pressure required for cochleary flow to supply the tissue with oxygen and nutrients and to remove the byproducts. How compartment syndrome results in a dead limb would be as follows. So initially clinical presentation patients would present with pain of the limb, pain swelling, they would complain of pain swelling edema on examination, the limb would be tender, the compartment might maybe tense. Can I ask you about the pathogenesis, pathophysiology of compartment syndrome and how that leads to a dead limb. So what happens is in compartment syndrome, if you've got, for example, gg crush injury, you've got damage to your muscle which results in edema, that the edema in the compartment results in the rise in the compartmental pressure which reduces the, once that pressure exceeds the pressure, the pressure required for cochleary flow to occur, there's no longer any flow, with no flow there's no oxygen supplying your tissue resulting in, ultimately a dead limb. Okay, you mentioned the infective causes of a dead limb, what a common cause you said necrotizing fasciitis, but I think it's a bit more than that. What infective causes do you have seen that has led to a dead limb? What was the underlying pathophysiology? Was it purely the infection, was there spider bite that led to so much infection that the limb was actually non salvageable? How does infection lead to, or what role does infection play in the dead limb? Is that a primary thing or do you think it's a secondary thing? So infection or toxins, for example spider bites or snake bites would result in a dead limb by means of the, for example compartment syndrome. Sorry, that's the only pathogenesis I can think of for both spider bites. What is the most common infected limb that you've ever seen that required amputation because the limb was un salvageable? A diabetic foot. A diabetic foot, so what's the pathogenesis behind the diabetic dead limb? There are multiple factors which play a role in resulting in necrotic eliminate in a diabetic patient. There are microvascular, macrovascular and neurological parts which contribute to it. So patients who are diabetic, firstly they already have a compromised supply. So when they have any source of infection which, sorry this is not an organised one to begin again. So the pathogenesis of a diabetic patient and a dead limb. Any insult to a diabetic patient's foot, be it due to trauma or a snake bite or rather any trauma or a world result doesn't heal as normally because the patient's got firstly pure blood flow. No, come on. What vascular pathophysiology does a diabetic have? So basically poly control diabetics have increased blood glucose leading to glycosylated hemoglobin and glycosylated other proteins also glycosylates which result in reduced or rather increased stiffness if you will of the blood vessel or capillary wall. Leading to reduced blood supply to the tissue. Ok, there are many factors in a diabetic which would result in a dead limb. Ok, but that certainly is the vascular issue as far as there is neurological things as well but vascular. Now you've got the patient with this diabetic foot. What criteria, what are all the aspects that you have to consider before deciding that this can be treated conservatively or requires immediate imputation? What are the criteria that you think about? So the criteria we think about is the patient's baseline and then the actual infection or presenting problem at hand. In terms of the patient's baseline, how is the patient's diabetic control, usually does the patient have any other comorbid factors, is the patient accounted for surgery, what is the patient's activities of daily living? In terms of the actual presenting problems of the dead or infected foot, I would want to assess the degree of the problem. So is it just a superficial infection that will be treated with antibiotics? Is it something that requires minimal debridement? Is it something that I've assessed on X-ray, it involves the bone and requires more extensive debridement, possibly amputation? That's how I would go about deciding. You've lost me a bit in as much as the specifics are concerned. If we just look at the clinical examination of the limb itself, what factors in the clinical examination would you consider to decide that this limb is salvageable? So basically assessing viability of the limb. I would look at the, so again the extent of the infection. I would assess the pulse status, assess sensation, see the degree of edema or erasema surrounding the infection. I would also, well, no, I would also ask the patient about just often patients with diabetes have other comorbid diseases. So often those smokers have atherosclerosis and would have peripheral vascular disease. So that would affect my management as well. You mentioned that this poorly controlled, my last question, poorly controlled diabetes leading to these vascular, micro vascular changes. Perhaps calcifications in the wall, et cetera, you mentioned the stiffness. Is the direct correlation with poor control versus how much vascular changes there are? Or can a well controlled diabetic also present with peripheral vascular disease and the complications of the diabetes? Is it purely the poor control? So there are two issues at hand, as I understand it. One, you can have a patient who is a diabetic only and that patient can have micro vascular complications secondary to their diabetes. Then you can have a patient who has two concurrent pathologies running so they can be diabetic. And they can also have peripheral vascular disease secondary to either the, or combination of factors, the smoking or the... My question really pertains to the fact, is this the poor control that leads to diabetic peripheral vascular disease? Or is it the disease of diabetics even if they are well controlled? You seem to have made that distinction, is that so? Is it direct correlation? Do you think? I don't have a question. Alright, my colleague will ask you a few questions. Now we needn't go as long as I did, but I just want to give you thinking your own question. Yes, it would be questions that might be pertinent in your mind. Questions that you would like answered or stuff that you've read. In terms of assessing the limits of whether you will amputate them up, I think you've done a very good job of elaborating on local sort of clinical features that would suggest a limb that needed to be amputated. Are there any sort of systemic features that you might focus on where you might sit there and think that this patient may require an amputation, if so would you elaborate a little bit on that? What I'm trying to say is a localized sepsis. The things you've discussed so far seem to pertain to a localized sepsis. Obviously that is not always the case in the way that diabetic horses and diabetic footsepsis presents. There are other sort of instances where you would strongly consider an amputation in terms of... Oh I see, okay. So you're basically alluding to the DKA of patients presented in severe derange hypoglycemic states. Not only DKA, but in terms of not just localized sepsis, but I'm talking more systemic sepsis. So according to the surviving sepsis guidelines, they've got many campaign bundles which basically guide our management in these cases. And one of the very important points that are brought out is that the source control. So if a patient came to me whether they were diabetic or not and they had systemic sepsis and we identified a source and the source was a limb that could be drained, divided or was so extensive in the initial assessment that required amputation, yes. So I suppose the answer would be that I would be guided by the surviving sepsis campaign which uses certain campaign bundles to guide our management, one of which includes source control. Others include illegal directed therapy, optimising the patient for theatre, ensuring patients often with diabetes have other comorbidities and we would optimise the hemoglobin to above 10. Other endpoints that we would aim for are a lactate level of below four. If not, you would administer fluid, repeat the lactate. Even that you would also measure CVP, I don't want to mention CVPomage. We would also aim for CVP between 8 and 12. I think we've done a good job in terms of covering the septic side of things. Obviously we've said before that not all ischemic legs require amputation. In another vein of assessing limbs, can you think of any traumatic related injuries that may require some sort of criteria to assist whether their limb needs to be amputated or not? And if so, then maybe perhaps elaborate on that for us. So something that comes to mind of patients with acute or severe trauma. So gosh trauma due to any mechanisms, train accidents, accidents related to work. So patients coming with severely mangled fingers or limbs for that matter. In terms of assessing the principles are pretty much the same. The question, well actually, there are two things that I would consider. One, the patient and under the patient would be the patient's comorbidities, et cetera. Not safety, ability to be operated on and then the actual problem. So the mangled limb is the pulse, how far does the tissue damage, how extensive is the bony involvement. In addition to that, so like local factors, when I say local hospital related, what facilities do we have, what are our surgeons capabilities, are we able to re-anestimise certain vessels or is it a case of we are doing a bit of damage control because we are poorly resourced. So that's not just patient factors that I would take into account. That wasn't recorded. Were you serious? Okay, apologies for that. My colleague is now going to ask you some questions. So we're going to be in keeping with the theme of vascular. How does the patient with, you mentioned acute and chronic causes of gangrene. Can you tell me how a patient with an acute cause of gangrene of the foot would present of the toe? In most of the cases that I have encountered is that most of these patients are elderly patients and most of them prefer vascular disease and on top of that they get acute presentation on the basis that they might have other comorbids and mainly patients with cardiovascular problems they can get emboli. Like patients with AF, they get emboli that goes down to the already diseased narrowed vessels in the preference and thus causing acute presentation of the chronic patient that is known with peripheral vascular disease. Okay, but what do these patients come in complaining of? Mainly presentations of these patients mainly acute presentations though they are known with chronic vascular disease they might have called claudications before that's a history that has been known they might have been following up in the clinic with their claudication but this presentation that presents now is an acute presentation that presents with pain complaining of sudden onset of pain it depends on how long the pain has been patients may present with parasitises as well they can also present with motor function loss of motor function as well on examinations so from the history you can get that patients have cardiovascular disease or they might be known with other vascular problems like patients who are having aneurysm they might have aneurysm above their level Okay, let's get you a little bit away from the history because you've covered that, I'm happy that you've covered it adequately but coming down to when you examine your patient now what do you see? Do your patients complain, they've come in, they've said the pain started, they've had two days the pain just won't go away What do they do? You're examining the patient now, what do you find? Okay, on examination of the patient you need to also initially inspect the limb looking on inspection of the limb you can see the limb is pale the limb is pale he can't move the limb or he can't move the limb but with pain this is some of the thing that you can see on inspection on examination the limb will be very cold compared to the other limb function wise patient may not be able to dorsiflex the limb that's also one of your examination that may give you now the criteria of whether you should categorize them as a fourth classification whether they are class one, class two, class three Tell me about the Rutherford classification Rutherford classification is classification of the presentation of the patient with an acute presentation of acute limb schemia and it's divided into Rutherford one, two, three and two and two B and Rutherford three Rutherford three being a dead limb that is unsalvegable and patient may need amputation depending on how unsalvegable the limb is Rutherford one is still a salvageable limb where patients present with parastasis pain but still they have motor function Rutherford two, two A still they can have motor function but the sensor is lost Rutherford two B there is no function where you need this patient to do a fascia to man see whether there is any muscles that are contracting or not otherwise they become better for three no dead amputation ok now I'm sure you've seen patients with necrotic dead limbs before ok so a patient comes in is obviously a non viable limb what are the causes that run through your mind as to reasons for a necrotic limb unsalvegable limb let's stick with the lower limb I think two broad categories depending on the patient would be your trauma patient that has an unsalvegable necrotic limb for reasons ascribed to trauma and then you have a patient that has underlying chronic disease specifically vascular disease that could be the cause of this so depending on your etiology or your underlying cause that would then definitely determine your project, your management of this patient can you be more specific about these groups now that you've described to us so in the trauma patient causes that I could immediately think of is the threat in them in terms of where you have a mangled limb you have underlying fractures and you have a patient that's sitting that had an untreated compartment syndrome where your blood flow was compromised you're saying a deep necrotic limb so this is a patient that's presenting quite late trauma is an underlying etiology but what happened is compartment syndrome et cetera and that's the cause of your limb obvious vascular injury and then you're when you're looking at your chronic disease patients is your vascular path your peripheral vascular disease which can be again this is a deep non-viber limb can further subdivide it into a patient with wet gangrenas limb or dry gangrenas limb in your dry gangrene you're thinking more chronic vasculopaths in your wet gangrene you're more thinking of your diabetics with nephropathic feet et cetera which can lead to this problem is there a patient that can have absolutely healthy beautiful arteries and present with a dead limb noe external trauma involved you've mentioned the diseased arterial system is there a patient that can present with a dead limb and they have beautifully normal peripheral arteries at this patients with deep venous complication this is one of the rare more serious complications of deep venous thrombosis would be your Surinia dolens over sorry I can't remember the exact amount or more severe complications of your deep venous thrombosis where your venous system is the underlying etiology of other common causes of nephropathic limb with normal peripheral arteries then complicated venous disease I suppose we've got severe obstructive disease noe it's a normal healthy artery yet but external compression I suppose you have to take external compression but more common than that you've mentioned the thrombosis what's the mechanism of embolas and how does an embolas cause a healthy artery to occur I use the term healthy loosely here these patients with the embola inherently have some underlying pathology that might lead to them having peripheral vascular disease but let's say early in the disease and they are healthy otherwise so how does the embola cause this occlusion where did the embola occur so one of the questions when you see patients with embola a phenomenon is that once again to determine the underlying etiology most commonly patients that you two big classes that you need to speak to mind would be patients with valvular heart disease and then patients your chronic intervenous gut users also commonly could present with embolic phenomenon so these patients need to be thoroughly investigated but that's just embola from hematological origin embola could also be infective and we also can get air embola you mentioned that beta is a very impassing what is the mechanism what is the pathophysiology and diabetics leading to peripheral vascular disease and unsalvageable limbs let me down the mechanism so the problem with diabetes is especially longstanding poorly controlled diabetes is end organ damage and besides the eyes and the kidney and the heart part of the peripheral problems that you deal with is peripheral neuropathies that these patients develop meaning that they've got atrophic changes peripherally to their feet and sometimes even hands where I think the most common these patients lose sensation in their feet they often injure themselves without knowing and because of compromised immunity they are already at increased risk for susceptibility to infection and decrease ability to fight it off so not only do they now have injuries that can't be attended to and they're not aware of but they also have underlying vulnerability to the sepsis and and then there is the micro vascular disease in itself which compromise tissue healing and wound healing so you see a patient with office diabetic foot sepsis what are the thoughts that run through your mind to decide whether this patient needs immediate ablation or they can be treated conservatively what are all the questions that are in your mind to help to guide you in making this decision okay so obviously you look would start by looking at the patient as a whole in general let's call it the eyeball test not that's maybe a bad term to wish but systemically how your patient is looking is this is there any signs of systemic sepsis which ofc would be immediate indication for sepsis control which was often would be ablation then if you look at the so that's a general part of the general assessment for me would also be your patient's glucose control that might not necessarily influence where when you would ablate the patient especially if the sepsis involved but it would give you a good indication as to how your post operative management of this patient might look in terms of the local sepsis first of all you need to assess the sepsis is it wet or dry dry not so common in your diabetics is it what's the level of spread is there pockets of these pockets of pus we need to x-ray is there any signs of osteitis boiling involvement gas in the soft tissue the surrounding cellulitis what is there the pattern of spread you also going to assess your vasculature which in diabetics not often easy to assess accurately especially if in acute sepsis patients are often edematous cellulitis difficult to assess you going to have to do Dopplers and discuss with your patient and plan the procedure which often might be a stage procedure so getting rid of the sepsis what would be the reason to be a stage procedure is to definitive amputation as your primary procedure how do you make that distinction well I think once again you have to look at your patient in general patient that's systemically septic where this is a case of sepsis control you would want to do the quickest procedure possible to get rid of the sepsis which most often is not a definitive procedure a TMA or a thrunie amputation quick less anesthetic time it's a resuscitated procedure in my mind if that's not the case it's a bit more at local factors when there is obvious pockets of pus or bone involvement but there is also spreading cellulitis where you can reason that you could get rid of the overt sepsis and pus and attempt in order to preserve some functionality treat the more superficial sepsis like the cellulitis with good broad spectrum antibiotics you know that would be one of the my colleagues can do ask you just a few short questions okay you're calling casualty to see a patient that presented a acute painful limb what are you approaching so once again a acute painful limb whether this is a patient with a history of trauma or whether this is a patient who has just acutely presented with this problem without necessarily a history who definitely you know influence how I would manage the patient should this be a patient that has had a history of trauma whether it be soft tissue or bony in representing the patient is a patient that is known with chronic vascular disease vascular disease would be a threatened limb so immediate assessment of the patient would be a full systematic evaluation of the patient in terms of history what is his current status is what do you mean by current status is it just a limb that's a problem or is this already a systemic problem in terms of the limb specifically let's go there is it just what exactly is the patient presenting with is it just a painful limb is it absent pulses is there already signs or evidence of tissue loss what is the extent of the vascular disease vascular disease is indeed what we are dealing with so there is various investigations that I could do to aid me in that this patient present in casualty doesn't have any tissue loss but he had been complaining about short distance colloadication in our presence with an acute onset of pain by your approach okay so what you are thinking is a acutely threatened limb here so once again it would be that this patient sounds as if he would be a candidate for a re-vascularisation procedure most important is to determine the level of disease and to then adequately prepare the patient for theatre so part of determining the level of disease would be a paraclinical examination is all these patients are going to go to theatre or you have a procedure where you can no you could have open vascular procedures and then you could have endovascular procedures as well which you can choose select certain patients for okay so clinical examination of the patient feeling impulsives testing sensation basically putting the patient in a rather scoring system might aid you in aids of special investigations like Doppler hand held Doppler what is that about classification can you tell us about rather for the classification classification 1 to 4 basically looks at pulse status and tissue loss unfortunately I can't remember the detail of the classification okay thank you okay so welcome to this oral examination I'm going to ask you a few questions and my colleague will take over from that okay I take for granted the fact that you've seen the endocrotic limbs before lower limbs I have yes okay after all of that interruption there are various causes for necrotic low limbs for necrotic legs what are the thoughts that run through your mind as to causes of non viable limbs that need oblation is this an acute setting any setting so from a broad category I look at in terms of timing or duration so acute ischemia and more chronic progressive things that have happened with acute break that down further into trauma traumatic causes and then vascular causes as well arterial venus thrombotic and embolic phenomena traumatic and further be broken broken down into physical trauma as well as toxins and bites and of course those sorts of things you could get this is by no means a comprehensive list but some way of breaking it down and then chronic forms very much in peripheral vascular disease would be progressive chronic form of ischemia lemoschemia and if I further differentiate further causes that would be a broad category let's go down you start with the acute very interestingly mention toxins as a cause of necrotic non viable limbs and from that I presume you mean exogenous or extrinsic toxins leading to non viable limbs have you got some more specific examples for that and what the pathogenesis is from that initial insult to the situation of the non viable limb so the traumatic toxin or it could be infective causes secondary to a bite unlikely to they could progress into a ischemic or a necrotic limb a bite from a dog a bite from a snake a bite from scorpions and those toxins can cause by what mechanism do they cause a non viable limb each bite would be different so in terms of a dog bite there's very many organisms within a dogs so that would be a later sort of subacute progression of an infective process and with snake bites you generally get you either get neurologic compromise or you get hematological compromise or you get ischemic vascular compromise from that's the question how do you get the vascular compromise the I don't know the exact I don't know the path of physiology of how a snake bite causes direct ischemia say for instance I have a cytotoxic snake how is that cytotoxic snake venom going to cause vascular occlusion or vascular flow occlusion at least in a necrotic limb through what mechanism through what syndrome it may not definitely be the sole mechanism but there is definitely micro thrombi and it's sort of a disseminated vascular inter vascular coagulation localised coagulation or micro thrombi that contribute to the ischemia and the development of the threatened limb and over and above that inflammatory process that further compromises the blood supply what happens in that compartment due to all these changes we see swelling increased blood flow initially increase and then decrease return of that blood flow what do we call that increase in the compartment in one of the compartments compartment syndrome okay compartment syndrome moving on to the more chronic side you mentioned the sepsis what's the leading cause or what's the most common cause of sepsis in a dead limb that you've seen I can't quantify in terms of in diabetics diabetics which would be the better physiology behind diabetics leading to a non viable diabetics is a predisposes to immunocompromise by the or being in a situation of immunocompromise compromise there are certain mechanisms for that one is of course the glycosylation of the white blood cells in the bloodstream further the actual peripheral vascular disease that happens with diabetes that atherosclerosis that they predispose to so if you have somebody at risk for infection and you have a decreased decreased blood supply to those areas and you have minimal trauma that combination can predispose to a infection that is inadequately controlled and progresses you see a patient with diabetic foot sepsis and you have to decide between consulative management and immediate ablation what thoughts lead you in that decision to make that decision between these two modalities of surgical management very good history also including social circumstances but if you need to be more aggressive you need to despite social circumstances a good history as to how long it's been other comorbidities that are associated with that and then obviously a very good examination with regard to having a look at the skin having a look at the pulses having a look at the atrophy having a look at the... give me an example of each of these that you mentioned how does that guide you between the two modalities ablation or consulative management I think more suggestive than history would obviously be your clinical examination so if I can lead more to that so the actual wound itself if there is gas in the wound if it's very very purulent if it is ascending and very erythematis if it's completely gangren as black then that would be more suggestive of more aggressive ablation to a level and also in a systemic point of view of course if somebody is more septic and the focus is that lesion then I would be more aggressive to try and achieve source control then obviously the actual use of their limb are really often you see they may be it's been long standing their limbs are contracted and fairly useless that would be more suggestive of if somebody has a completely contracted knee and distal ischemia would suggest more aggressive I can suggest you the patient rather than the diabetic foot set that says external trauma any form of external trauma what are the thoughts that might lead you to decide between ablation as far as the external trauma is concerned versus reconstruction and consulative management what would be the factors that would influence you to decide to rather amputate the limb from external trauma rather than to try and save the limb if I look at the limb the soft tissue the bone and the nerve involved in that limb the soft tissue is very very important to supply the nerve and the limb the nerve and the bone with adequate nutrition and support so if you have completely devitonised limb or soft tissue that is very very contaminated and torn sort of a mangled limb that would be more suggestive of ablation very comminuted fractures in multiple places that's not amenable to x fixing then that would be more suggestive of a more aggressive surgery and of course with nerve if you have transactions complete transactions and drop foot and those sorts of things that would also be very unlikely to recover and that would be more suggestive of aggressive surgery and blood supply if you have it depends on obviously how long but if you had a traumatic aneurysm and that has been missed and the leg has come back dead then of course that would need more aggressive surgery okay thank you my colleague will ask you a few short questions you mentioned the compartment syndrome earlier how would you go about diagnosing a compartment syndrome in context just to give you a sort of clinical suspicion and then of course on a clinical examination commonly referred to the 5, 6 there are many p's involved but palo pulsusness parasthesia as well as paralysis polythermia or coolness to the limb and there has been referenced in purple but I guess that's also in the same the same context but that would be very suggestive compartment pressures compartment syndrome is when you have increased pressures within a confined space where your fascial confined within a limb and that pressure is often referred to as 25 to 30 millimeters of mercury and then you have that sort of syndrome of those 5 p's that's a context of in history of trauma or a bite or something that would be in your own compartment syndrome in a patient with a low limb compartment syndrome how would you go ahead and manage the problem if somebody has the concern is is ischemia so you would need to relieve those pressures in order to salvage to salvage the limb and reap the fuse obviously being very wary of reap the fuse and not going to try and salvage a limb and sacrifice the patient at the same time but you would need to do fasciotomies if they clinically indicated and with a fasciotomy of a lower limb we would do two incisions one on the medial aspect just posterior to your in one of the lateral aspect and that would give you access to all four compartments within the leg in order to decompress the fasciaal confines and re-institutes adequate perfusion you mentioned reperfusion syndrome what do you understand under so reperfusion is a scenario where you have had ischemia and the tissues have been compromised ischemia by virtue withheld of blood so they haven't had adequate blood supply for a period of time en because of that you have the poor functioning of the cells on a cellular level you have poor functioning of the cells a lot of electrolyte abnormalities are being then re-instituted blood and those electrolyte abnormalities can reperfuse particularly calcium potassium acetic acidosis patients had risk for that on a systemic level because of the by-products of anaerobic metabolism at a local limb level is there anything that you can do to prevent or minimise the effect of some reperfusion syndrome I think be very wary of it in these sort of contexts before so always try and prevent it and always think ahead if you're going to have that sort of scenario always keep your patients well hydrated there is is growing literature towards antioxidant treatment and to have that bury that in mind high dose vitamin C is one mannitol is another and has been referred to the efficacy of that is full debate but it is a method that is used at a good hydration and of course monitoring of these electronics in that context and aggressive replacements or even dialysis if need be so I'm going to ask you a few questions my colleague will then take over and it's going to pertain of course to vascular surgery a patient presents to you with two casual tear referred to you with acute lump pain cannot absolutely stand that pain the patient has never had it before has never compared with claudication and giving you a clue obviously that this is about vascular surgery what is your work up of this patient what are your thought processes as two possible causes and your eventual management right from the description of the patient sounds like this is a patient who is suffering from something called ischemic pain and ischemic pain is pain we defined as pain derived from vascular compromise of a limb particularly the tissues of that limb including the muscles, the nerves and relevant connective tissue this patient like we've already stabbed is suffering from some sort of vascular insult and when we talk about vascular insults we talk about thrombotic events we talk about embolic events to me it sounds as if this patient is lying on more along the embolic root which involves and that's given away by the fact that there's no claudication history of what's ever so this is an acute new onset event which is sort of typical of embolic events just in terms of the embolic event embolisis in this case would be described as a foreign sort of material that is included a blood vessel and is now compromising the circulation of the tissues as we said before which is resulting in the patient's ischemic pain in terms of the work up of this patient trying to establish what is the cause of this embolis and where that embolis has come from you would first obviously establish whether the patient is stable following your ABCs of ATLS principles make sure everything is fine this patient does need any form of resuscitation a particular concern is the fact that one of the major originating areas of embolic events is atrial fibrillation so obviously you want to make the patient's cardiovascular stable in particular but that's just focusing on the ABCs we'll get back to that now you would obviously now establish that the patient is stable and once they are stable you can determine that this patient is now eligible for investigations so investigations that I would sorry I'm jumping the gun a little bit we want to start with the history taking again you want to establish onset of pain particularly maximum pain in terms of establishing ischemic time the golden sort of time period that you're looking for is under 6 hours and that's in terms of revascularizing with intent of having viable tissue afterwards you would also want to know if the patient had any previous surgeries where the patient's got any comorbid medical disease that may contribute to vascular pathology includes diabetes, hypertension any sort of other vascular events that the patient has had in terms of the patient's history itself you would talk about provocation is just to establish where there's any underlying vascular pathology and that's important not only just in terms of establishing the cause but you would also establish what kind of treatment this patient would get obviously trying to treat a patient that's really got to compromise in terms of vascular pathology would be a little bit more difficult than an acute onset with healthy arteries let's suggest that this patient has had as a no-cordication and that you clearly suspect an embolic event in a patient with clinical examinations found you want to have atrial fibrillation and what would be the clinical findings in a patient with acute embolic event with no underlying atherosclerosis the acute embolic event again going into history would be the acute onset of sudden pain moving on to the clinical examination depending on what level that embolus was now sitting typically with embola thrown up from atrial fibrillation you would expect I would want to say for glove and stocking kind of a distribution of the ischemia you would probably find that the toes are now becoming ischemic in terms of the time those toes may be gangrenous early signs of that ischemia would include parasthesia swelling of the extremity pain out of proportion you may start seeing skin discoloration you may have pulsuses limbs but that would come quite significantly later and that's in terms of the now clinical examination you know it suggests that that's a showering of smaller emboli how would that differ from a patient who shoots off a sizable embolus that say for instance includes the bifurcation of the common femoral artery now we're talking about a ischemic event of a much larger tissue surface area which comes with a whole myriad of problems particularly now like I said before you would look for signs of ischemic compromise and that would be pain out of keeping pulsus limb parasthesia swelling of that limb obviously now with the ischemic events going on blood flow is not circulating to the cells particularly the muscles and the nerves and the bone of that tissue each of them have their own preference in terms of ischemic times but with the lack of blood flow you have a lack of oxygen nutrition that leads to destruction of sort of cell membrane action potential pumps cells now start swelling and start activating calcium mediated sort of just looking at the limb what does it look like compared to the other one it will be swollen it will be pale it may have pale in the early stages may be discoloured later on palpation the limb will usually be quite tender as opposed to the other one it might be swollen compared to the other one that is obviously with the cell destruction that is going on and obviously decreased pulsus or absent pulsus distally as far as temperatures concerned the ischemic will obviously be a lot colder it will be a lot colder okay you mentioned warm ischemic time so certainly you don't have ample time to play with are there any special investigations that you would consider in this patient special investigations look again time is something that you need to not play with special investigations to investigate sort of vascular pathology this is now not looking at the origin of this in terms of looking and establishing the level of the ischemia you could consider a angiogram doplers sorry before that you could consider doplers flow doplers you could look at certain ultrasound investigations but I think that would be quite hard to establish to arterial insufficiencies but I would think that the gold standard would be an angiogram to establish exactly where it is okay the patient has a white a white kidney threatened limb right with no history a preceding history suggest of peripheral vascular disease is the arteriogram a waste of time because time is of the essence or is there something that you can learn from that from that formal dsa of ct angiogram look ct angiogram would give you a sort of cut off level could you learn that from clinical examination you would know with the establishment of the embolus is now sitting but in terms of the exact size and propagation of that embolus in other words it may be difficult to treat a long kind of segment of embolus where as a shorter segment might be how is the angiogram going to show you that it probably wouldn't actually because it would have a cut off so it wouldn't show you the distal segment so probably not I would think you might establish it in more chronic diseases collateral but that's about as well just talking in broad terms about the surgical management of this patient what are the principles involved in an embolectin at the level of the bifucation of the common femo the principles involved in an embolectin is obviously to surgical principles you are performing the embolectin we won't elaborate on the pre-op preparation of the patient we will try to show the procedure itself what you need to do is to have adequate exposure the vessel involved in what you tend to in surgical catheter in this case I would think that sure if it's something at the bifucation of common iliac surgical principles I am exposing the artery you would have adequate exposure to the artery you would want proximal and distal control you would want to enter the vessel in a sterile and safe manner you would advance your guide wire through the okay so I've got proximal, I've got good exposure I've got proximal distal control what is the proximal control of what vessel at the bifucation or would you know the common iliac or would it be the artery it would be the distal auto I suppose you are exposing the vessel in the groin for an embolectin where is your proximal control proximal control would be more towards the sterile what artery do you sling the common iliac the common iliac why would you want to go that high sorry I thought we said that the embolist was sitting at the common femoral sorry the common femoral right so you would go to the the internal external iliac vessel what is the distinction between the external iliac and the common femoral where is the name change sorry it is at the level of the inguinal iliac see would it cut through the inguinal iliac no you don't so the proximal control is up there of the proximal femoral artery the common femoral before you make your incision would be more distal I wouldn't go down as far as the property artery would sort of mid common femoral or femoral vessel distal to the to the origin of the what are the two vessels distal to the bifurcation distal to the bifurcation or the common femoral is your perfundus and then your femoral artery itself better known as the something femoral artery your perfundus femoral artery and don't superficial femoral artery so you need control over all three of those vessels unless you can make your incision the blood is going to the blood is going to squirt up to the roof is there something that you should administer to the patient before you occlude those arteries before your incision the patient so you make your incision now what? you would remove the cut of blood that is clearly visible obviously your intention is to be on the distal end of the clot you would now advance your your guard wire sorry the principle will be using a foggy de catheter I don't think there is a guard wire in both but you would advance your foggy de catheter through the clot you obviously wouldn't be doing this under fluoroscopy and the intention would be to advance it up until the point that you were getting fresh arterial blood through the I'm so crushing it the principle behind it would be to advance the foggy de catheter through the clot inflate it and retract the clot out and remove it that way the exact details is where the the guard wire is involved so you get clot out how do you know that your procedure is now adequate you would have good flow from the vessel so would you just remove the clot to go down both vessels or just one you would probably go down both vessels okay so you close up the artery now how do you release your clams you've got control over all these three vessels now you would release your distal clamp first and then you would release your proximal why the distal first before you tell your last week sorry I retract that statement I would release the proximal clamp first assess whether you have got any active bleeding from your repair and then if that is I think enough my colleague is going to ask you a few questions before I correct your numerous technical mistakes okay were this patient perioperatively what sort of complications in broad turns what sort of complications did you consider any time we discussed complications involving any procedure we want to talk about early we've obviously discussed the interoperative complication we will not talk about the early perioperative complications and then the late perioperative complications early perioperative complications would include further bleeding from the sut damage to vessels vessels and arteries that would have been sustained that are now becoming evident after the procedure if there is a closed bleed there would be a hematoma formation also possibly AV malformation depending on what are your two genetic injuries were caused by the thing the hematoma itself could cause pressure compromise of the area including nerves and arteries and veins you could get an infection in the site which would obviously form more under your intermediate to late complications and then obviously any time you're involving the vascular system you must worry about thromboemolism that could form from the procedure itself we'll be on to late complications I'm bored of that please so the thromboemolism that would form we said we're going to anticoagulate our patients when about in this whole time do you anticoagulate in terms of the exact sort of time frame in terms of number of days prior to procedure is not something I'm 100% familiar with but I would think if you're going to now do a procedure I think at least 6 hours prior to procedure you would need to start but this is an emergency procedure well then you would need to if it's an emergency you would have to pretty much give it just prior to operation and then interoperatively and then continue that on do you have any idea on how to give the anticoagulation in this instance in terms of depending on which form of anticoagulation you choose to use with this low I would preferably use low molecular weight heparin and that's because it's been shown to have as much benefit as unfractionated heparin but far fewer complications and obviously you don't have to monitor the low molecular weight heparin as much as you do the confractionated heparin I think in this instance correct me if I'm wrong we're using infusion of unfractionated heparin to be able to monitor perioperative and also as a therapeutic not only I think in the context that you speaking of is from prophylaxis so we using as treatment doses of infractionated heparin infusion okay alright so welcome to the oral examination I'm going to ask you whether you've seen patients with necrotic unsalvigable dead legs before plenty I'm sure what are the causes of necrotic unsalvigable dead limbs that run through your mind when you see a patient what are all the possibilities as far as causes are concerned acute acute limbischemia can be chronic limbischemia with an acute onset and it can be a chronic on itself so in the acute setting it could be trauma it could be a dysloge thrombus thromboembolic disease it could be intimal injury that has so an embolic source can come from the heart patients with atrial fibrillation it could be an intimal injury which has caused thrombosis and then an emboli which has gone distally and caused an acute limb acute on chronic could be a patient who has already a chronic atherosclerotic disease which has now and has an acute hit on that which could also be trauma all those things that I've mentioned already in such patients you get atherosclerosis which can lead through a thrombus formation in itself and that can also include acutely and then there's the chronic the chronic limbs which take a natural progression of which one of third get better one of third remain the same and one third get worse and that could be with patients with risk factors of diabetes smoking, hypertension and hypercholestering so those are innately arterial causes of a dead limb are they non arterial causes of a dead limb in essence every one of them has to end up being no blood flow but you've mentioned sort of interluminal causes are they other causes as far as all these dead limbs that you've seen before it can be or should I say you've mentioned all the large vessel causes are there other causes of non viable legs they can be compartment syndrome which can be caused by different reasons one of them could be trauma then they could be a simple pop causing external compression could be other causes of compartment syndrome what about toxic causes it could be from a snake bite which causes like crosses it could be from I think those would be ones that we've all seen before you mentioned diabetes in these chronic patients what is the pathophysiology of diabetics leading to non viable limbs why did diabetics develop non viable limbs it's the pathogenesis it causes diabetes causes injury to the micro vasculature and it also predisposes to hypercholesteringia which increases the atherosclerotic disease so there is micro vascular damage which then leads to propagation of fibroblast which then leads to fibrin deposition which then leads to cholesterol deposition and a thrombus now you see a patient with diabetic limb diabetic sepsis the mechanism that you've mentioned infected how do you decide what guides in your decision to decide whether to amputate this leg to the enablation or to manage diabetic sepsis conservative what are factors that you would consider making this decision okay I want to first assess if the limb is viable or not and you want to go through and then you want to see if there is wet gangrene or not which could in a patient who has in a patient who has hyper glycemia would predispose more infection so you want to assess if the limb is viable itself how would you go about that how would you make that decision okay if a patient is spreading sepsis with a patient who has a leg which is obviously not viable or a foot or a toe that's not viable how do you assess that how do you know it's not viable well there's three classifications I'm just talking diabetic foot diabetic foot with sepsis what are the other things that help you to decide whether this patient needs to go straight to theater and have the leg amputated or you can treat it conservative with antibiotics and blessings okay you want to which patient or sketched to me the patient that needs to go directly to theater and have an ablation okay I look at the x-ray there's gas in the soft tissue he needs an ablation if there is if there's obviously a black toe distilled that needs ablation if there's a patient who has are there any systemic symptoms in size a patient who has sepsis a patient with an obvious like tachycardia with raised white blood cells with a high or low temperature normal to subnormal an increased respiratory rate because the signs of systemic sepsis okay I want to move you from the diabetic that you have to decide to amputate or not maybe to the external trauma patient patient with external trauma what factors would influence you to not try and salvage the slim by various procedures rather than to amputate a lower limb what findings in a acute trauma will lead you to amputate a limb okay there's all that option of a mangled limb reconstruction versus all this early early amputation you amputate early the patient heals better goes home whereas you do many procedures and they fail so there's the mangled limb score whereas in an acute setting obviously the foot is dead the foot is dead it's a Rutherford 3 and it's unsolvageable you'd want to do an early amputation but the other things that would influence you is you look at how many structures that are damaged that's the soft tissue, the bone the nerves the blood vessels the blood vessels which include the artery and the vein so there's no point of saving a foot that has an obvious peronial nerve injury that's going to cause a foot drop so you look at the mangled limb score and assess from there on us in the way that come up with this influences you or other injuries well yes if a patient is you want to do damage control surgery also so if a patient is on a massive transfusion is hypothermic is oozing so you want to do damage control as well life of a limb ok thank you my colleague will ask you a few short questions I think the the basket questions have been covered quite well in Dr. Crawford's in terms of complications one could expect post amputation of a limb let's talk about a diabetic limb now going back to the diabetes you've now amputated dysplation so it's a baloney amputation what also the the perioperative complications one would expect with the amputated limb so the perioperative meaning intra-op we'll go past the intra-operative complications straight to the procedure ok so you get the immediate the early and the late so in the sorry it's a diabetic amputated baloney amputation for a diabetic person so it is the immediate the early and the late the immediate would be of course you want to control the hyperglycemia you want to control the bleeding you want to make sure hyperglycemia bleeding you want to decrease the perioperative time we're talking about complications now in the post-operative period I'm talking now in terms of you and now you've operated this patient what are some of the complications one might expect and what one might pre-empt and actively maybe sort of intervene in discuss those complications you're doing fine in terms of the early and late complications but focus particularly on now on early and late complications and how would you manage dysplation in one of the things you would look for how would you how was any medications that you would add to the patient's treatment that would now help the patient okay so number one there would be there would be the bleeding which you want to make sure you want to get you want to assess on the dressing changes you want to look at the infection so you want to make sure the hyperglycemia is well controlled the patient is on adequate antibiotics you want to also make sure that the wound doesn't break down so these you know assuming you had good technique in drop and the wound wasn't under tension and all then you want to manage this chronic illnesses as well because that can lead to hyperperfusion of the affected limb like adequate blood pressure control and all and then the the late complications would then be for the stump breakdown would be reinfection particularly in terms of the vascular sort of trend you know I have a diabetic patient also be hypertensive who has now had an amputation what are some of the factors that would influence your decision to treat this patient procedure or medication now the patient now is a mobile in the world she used to be able to walk around she cannot walk around anymore what would you would you consider any sort of prophylaxis against something in particular okay what I'm trying to say would you put this patient on dbt prophylaxis now and the patients haven't been offered yes of course yes is any particular dbt prophylaxis you would prefer in this patient and if so why well I would I prefer klexin over hyperin because of the it's easy to administer it gets gets better it's well controlled the hyperin is a bit tricky in terms of it's you have to do a lot of it's difficult to administer just because of the doses itself I put him on a prophylaxis dose which is half half milligram per kilogram we're not particularly we're more concerned with the principles here not so much the dosing right so you'd put this patient on dbt prophylaxis you would choose an fracturing approach you would think is a wild choice let's go back to sort of assessing this a little now you've decided to do an amputation on this patient say the sepsis is is somewhere sort of mid cough area what are those sort of influencing factors that you would look at in terms of the level of amputation you would do in this patient okay so I want to see at what level at what level the sepsis is and then how would you be guided by that what are you looking for in terms of that in terms of well you want to look at the things that are causing inflammation in that area so basically that would be redness that would be how far the foot is warm just the swelling of the foot or that part of the leg so you want to go just proximal to that especially in a patient who you know can tolerate a surgery later on you want to just you want to do a guillotine and then come back to later formalize to make sure the sepsis is under control in terms of baloney amputation obviously there's a certain point at which you're cutting a bit too high do you know what that level is now soliciting it and why we sort of look at that level and why it's important sorry you said that again you've just said we'll go to the level of air thema the sounds of infection but now in terms of baloney amputation so if it's up to mid calf level I want to see if I can well this is what I would do personally I want to see if I can get it at an area where I can do a guillotine and still preserve a bit of a flap that can later be formalized as a BKA but in a case where I feel like I can't leave a flap enough it's better to do a trunie and then later formalize it as an above me amputation