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Acute Limb Ischemia

Ns. Rambu Inanda Dwihasti, SKep

Perawat Pelaksana ICVCU

Acute Limb Ischemia

Definisi, Etiologi & Patofisiologi

Acute Limb Ischemia

Evaluasi Klinis & Kelas

Acute Limb Ischemia

Managemen

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DefinisiAcute Limb Ischemia

Penurunan perfusi

tiba-tiba pd arteriekstremitas yg

menyebabkan

ancaman viabilitasekstremitas

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Etiologiacute limb ischemia

Acute arterial embolism:

Acute traumatic ischemia:

Scr relatif pd cabang arteri sehat tree

(arrhythmia, cardiomyopathy, sheath,

oklusi Percutaneous Transluminal

Artery )

Acute arterial thrombosis: Seblmnya ada penyakit pdpcabangan arteri (atherosclerosis)

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Insiden

Laki-laki > Wanita pd trombosis

Laki-laki = Wanita pd emboli

Ekstremitas atas < Ekstremitas bawah

Mortalitas = 7 - 29%

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Pato-fisiologi

Iskemik Emboli

Akut

IskemikTrombosisAkut

Emboli tiba2

menyumbat

percabangan

arteri yg sehat

Atherosklerosis

menyebabkan

penyempitan

cabang arteri scr

progresif

Mstimulus

pbentukan

kolateral

Aliran

melambat &

permukaan

kasar dpt

msebabkan

trombosis akut

Biasanya

menetap pd

bifurkasi

arteri

Aortic bifurcation

Iliac bifurcation

Femoral bifurcation

Popliteal trifurcation

Emboli dpt berasal dr jtg (MS dgn atrial fibrillation, MI dgn mural

thrombus)atau dilated diseased arteries

(aneurisma aorta)

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Penting untuk membedakan antara iskemik

emboli & trombosis : berbeda

management

Oklusi embolik harus dicurigai pada pasien dengan

corak sebagai berikut:

Onset simptom tiba-tiba

Diketahui sumber emboli

Tidak terdpt riwayat utama dari klaudikasio intermitten

Denyut nadi normal pada anggota gerak yang tidak

terkena.

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Severitas iskemik akut tgantung pd:

a)Kemampuan dr kolateral yg ada u/ mbawa drh di sekitar area obstruksi akut

(kolateral tumbuh pd psn dgn

preexisting chronic ischemia)

Oleh krn itu, emboli arteri

cenderung msebabkan gejala yg

tiba-tiba & iskemik severedibanding dgn trombosis arteri

b) Lokasi obstruksi b.d jmlh pcabangan arteri

Postgraduates

Aorta & common iliac One axial a. with limited collateral pathways

Internal & external iliac Two axial aa. With better collateral potentials

Two axial aa. With better collateral potentialsSuperficial & deep femoral

Popliteal artery One axial a. with limited collateral pathways

Three axial aa. with better collateral potentialsTibial arteries

c) Luas obstruksiSemakin besar obstruksi yg tjd, semakin byk

kolateral yg hilangd)Lama

Aliran distal pd obstruksi melambat. Jika kolateral tdk dpt me

aliran drh pd area tsb, hambatan aliran drh akan menetap pd

area distal pcabangan arteri. Heparin hrs diberikan sedinimungkin

For Example:

Popliteal a occlusion (a

single axial a.) results insevere ischemia, while

posterior tibial occlusion

may be asymptomatic if

other leg arteries are

patent

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Definition:Sudden decrease of arterial limb perfusion causing threat to limb viability

Etiology:1-Embolic(Rh.heart w mitral stenosis & AFor Ischemic heart w acute myocardialinfarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)

2-Thrombotic acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia

Clinical Picture

Management

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Evaluasi Klinik Iskemik Akut (GambaranKlinik)

Gejala iskemik akut:

Nyeri: Nyeri hebat pd ekstremitas pd fase akut(more acute in embolic ischemia)

Intensitas nyeri dpt me seiring dgn wkt bila ada kolateral yg mpbaiki sirkulasi, atau jika

pkembangan iskemik msebabkan hilangnya sensori iskemik

Dingin adalah gejala awal

Baal diikuti oleh hilangnya sensori (late)

Kelemahan otot (heavy limb) diikuti oleh paralisis (late)

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Evaluasi Klinis Acute Ischemia

(Gambaran Klinis)

Riwayat

Tujuan pertanyaan

1- U/ mengetahui apakah gejala2 yg muncul sifatnya akut iskemik atau bkn

(DD of acute ischemia : acute DVT [phlegmasia], hypo-perfusion states [e.g. heart

failure specially if associated with chronic ischemia]

2- U/ mengetahui tingkat keparahan acut iskemik

(ask about symptoms of different classes of acute ischemia see later)

3- U/ mencari penyebab

(ask about Rh. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath.,

risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia,family history of cardio-vascular disease)

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Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

5PsPain: gejala

+

Pulseless

Pale

Parathesia

Paralysis

Inspeksi

warna:

Awal: pale

Lanjut: sianosis mottling fixed

mottling & sianosis

Pallor

Reversible

mottling

An area offixed cyanosis

surrounded by

reversible

mottling

Empty veins:

bandingkan dgn

kanan (iskemik) &

kiri (normal)

Fixed

mottling &

sianosis

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Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

5PsPain: gejala

+

Pulseless

Pale

Parathesia

Paralysis

Palpasi

Femoral Popliteal

Posterior tibial Dorsalis pedis

Palpasi pulsasi perifer, bandingkan dgnekstremitas yg lain & beri tanda

Temperatur: ekstremitas teraba dingin dgn(bandingkan diantara ekstremitas kiri & kanan)

Slow capillary refilling setelah tekanan jari

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Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

5PsPain: gejala

+

Pulseless

Pale

Parathesia

Paralysis

Palpasi

Hilangnya fungsi sensori

Dr mulai baal s/d anestesia

Progress dr kehilangan

sensoriSentuhan halus

Sensasi Vibrasi

proprioreseptor

Nyeri dalamSensasi tekan

Late

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Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

5PsPain: gejala

+

Pulseless

Pale

Parathesia

Paralysis

Palpasi

Hilangnya fungsi motorik:

MIndicatesadvanced limb threateningischemia

Late irreversible ischemia: Bengkak otot

Otot telapak adlh yg pertama kali

terkena, di ikuti o/ otot tungkai

Mdeteksi kelemahan otot scr dini

adlh sukar krn pgerakan jari2

dihasilkan yg utama o/ otot tungkai

Postgraduates

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Classes of Acute Ischemia

Clinical Findings Doppler Prognosis

Class Sensoryloss

Motorweakness

Arterial

signals

Venous

Signals

I.Viable -ve -ve audible audible Not immediatelythreatened

II.aMarginalthreat

Minimal

sensory loss

No muscle

weakness

Often not

audible

audible Salvageable if prompt

ttt (there is time forangiography)

II.b Immediatethreat

Rest pain wsensory lossmore than toes

Mild tomoderate

Usuallynot

audible

audible Salvageable withimmediate ttt (no time

for angiography)

III.Irreversible Severe

anesthesia

Paralysis wmuscle rigor

Inaudible Inaudible Not salvageable,permanent N. & muscle

damage ,needs amputation

Postgraduates

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Definition:Sudden decrease of arterial limb perfusion causing threat to limb viability

Etiology:1-Embolic (Rh.heart w mitral stenosis & AFor Ischemic heart w acute myocardialinfarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)

2-Thrombotic acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia

Clinical Picture

Management

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

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Investigasiacute limb ischemia

Severitas dan durasi iskemik mberikan batasan waktu yg sempit

pemeriksaan

Doppler Ultra Sound

Penting u/ melihat arteri,mkaji tingkat obstruksi &

itngkat keparahan

iskemik

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Arteriografi

Investigasiacute limb ischemia

Patients with high clinical probability ofembolic ischemia do NOT need angiography

If the differentiation between

embolic & thrombotic ischemia is

not clear clinically, and if the limb

condition permits,

DO ANGIOGRAPHY

Value of angiography

Localizes the obstruction

Visualize the arterial tree & distal

run-off

Can diagnose an embolus:

Sharp cutoff, reversed meniscus or clot

silhouette

Popliteal embolism

Reversed meniscus sign

Lt. iliac embolism

Clot silhouette

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Treatment of acute limb ischemia

A Once diagnosed

Immediate anticoagulation with heparin to avoid clotpropagation

Appropriate analgesia

Simple measures to improve existing perfusion:

Keep the foot dependant

Avoid pressure over the heal

Avoid extremes of temperature (cold induces vasospasm, heal raises themetabolic rate)

Maximum tissue oxygenation (oxygen inhalation)

Correct hypotension

Start treatment of other associated cardiac conditions (CHF, AF)

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Treatment of acute limb ischemia

B Catheter directed thrombolysis

Indications:

1. Viable or marginally threatened limb (class I, IIa)

2. Recent acute thrombosis (not suitable for embolism or old thrombi)

3. Avoid patients with contraindications

Agents used: Streptokinase,

Urokinase, tissue plasminogen

activator

Contraindications:

Absolute:

1. Cerebro-vascular stroke within previous 2 months

2. Active bleeding or recent GI bleeding within previous 10 days

3. Intracranial trauma or neurosurgery within previous 3 months

Relative:

1. Cardio-pulmonary resuscitation within previous 10 days

2. Major surgery or trauma within previous 10 days

3. Uncontrolled hypertension

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Treatment of acute limb ischemia

C Surgery

1- Acute embolism: Catheterembolectomy under local anesthesia

2- Immediate surgical revascularization is indicated in class IIb, or class I, IIa

when thrombolysis is not possible or contraindicated

A combination of different procedures can be done:

Arterial exploration at different sites

Arterial thrombectomy

Bypass surgery based on pre-operative

angiography if available or intra-operative

angiography

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Embolectomy

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Following revascularization:

The sudden return of oxygenated blood to the acutely

ischemic muscles generates & releases oxygen free radicalsthat causes cellular injury and severe edema

Compartment syndrome

& muscle necrosis

ttt

FasciotomyLongitudinal incision of the skin & deep fascia to release pressure over swollen muscles

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Amputation:

Done for irreversible ischemia with permanent tissuedamage (turgid muscles, fixed cyanosis)

The level of amputation is decided according to the level of

palpable pulse.

Palpable popliteal pulse -------------- Below knee amputation

Absent popliteal pulse ---------------- Above knee amputation

D fi iti S dd d f t i l li b f i i th t t li b i bilit

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Definition:Sudden decrease of arterial limb perfusion causing threat to limb viability

Etiology:1-Embolic (Rh.heart w mitral stenosis & AFor Ischemic heart w acute myocardialinfarction & mural thrombus or extra-cardiac embolism from aneurismal arteries)

2-Thrombotic acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals)

Other factors determine the severity of acute ischemia

Clinical Picture

Investigations

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

Dopplerto evaluate level & degree of ischemia

Conventional angiography in class I & IIa

Intraoperative angiography in class IIb

Treatment Heparin

Catheter directed thrombolysis

Operative revascularization

Amputation in irreversible ischemia

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Pengkajian

Riwayat Penyakit

Tujuan dr pertanyaan

1- U/ mengetahui apakah gejala yg timbul adlh akut iskemik atau bkn

2- U/ mengetahui severitas iskemik akut

3- U mencari etiologi

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Pengkajian

Kemunculan penyakit (5P)

Keluhan pain/nyeri: Onset, durasi,

intensitas, lokasi

Pallor

Paresthesia

Paralysis

pulselessness

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Pengkajian

Riwayat dahulu Apakah pasien mempunyai nyeri pada kaki

sebelumnya (seperti, riwayat klaudikasio)

Apakah telah diintervensi untuk sirkulasi yang

buruk pada masa lampau Apakah didiagnosis memiliki penyakit jantung(seperti, atrial fibrilasi) maupun aneurisma(seperti, kemungkinan sumber emboli)

Apakah memiliki penyakit serius yang

berbarengan atau faktor resiko aterosklerotik(hipertensi, diabetes, penggunaan tembakau,hiperlipidemia, riwayat keluarga terhadapserangan jantung, stroke, jendalan darah, atauamputasi.)

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Pengkajian

Pemeriksaan Fisik

Pulsasi

Warna dan temperatur

Kehilangan fungsi sensoris

Kehilangan fungsi motorik

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Diagnosa Keperawatan

Ggn perfusi jaringan b.d tidak adanya

suplai darah pd jaringan ekstremitas

Ggn rasa nyaman nyeri b.d penurunan

suplai oksigen

Ggn pemenuhan kebutuhan sehari-hari

b.d kelemahan anggota gerak

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Intervensi Keperawatan

Observasi keluhan nyeri

Observasi TTV

Observasi pulsasi Hindari penekanan pd area yg sehat

Hindari temperatur yg berlebihan

Kolaborasi: analgesik, atasipenyebab,pemeriksaan dopler-angiografi,

terapi trombolitik, tindakan bedah

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