Case Details

Cardiology

Indian Doctors Network posted a case

over 1 year ago

SUDDEN ARM PAIN

Courtesy: 100 cases in surgery

History
A 59-year-old woman presents to the emergency department with pain and tingling in the right arm. The pain occurred that morning while she was walking the dog. It was sudden in onset and has improved since arriving in the department. There is no history of trauma and she has had no previous episodes. She is now able to move her fingers, but says they
feel numb. Her previous medical history includes intermittent episodes of palpitations for
which she is waiting to see a cardiologist.

Examination
The right hand appears pale and feels cool to touch. The radial and ulnar arterial pulses are absent. There is no muscle tenderness in the forearm and she has a full range of active movement in the hand. Sensation is mildly reduced.
An urgent angiogram is performed and an electrocardiogram.

Questions
• What is the likely diagnosis?
• What is the probable aetiology?
• What other aetiologies do you know for
this condition?
• How would you investigate and manage
this patient?

ANSWER
This is an acutely ischemic limb secondary to arterial embolism.

The embolus is likely to have originated from the left atrium as the patient has atrial fibrillation (shown on the ECG).
Aetiologies include:
• cardiac arrhythmias: commonly atrial fibrillation
• aneurysmal disease
• procoagulant state caused by underlying malignancy
• thrombophilias
• atrial myxomas.

Investigations aim to determine the aetiology of the embolism and to prepare the patient
for theatre:
• full blood count (polycythaemia)
• clotting
• group and save
• ECG (arrhythmias)
• chest X-ray (underlying malignancy).

The patient should be given heparin and resuscitated with intravenous fluids and analgesia.Loss of sensation and paralysis in the affected limb (signs of advanced ischaemia) are indications for urgent embolectomy. A postoperative echocardiogram is arranged if preoperative investigations do not reveal an obvious cause for the embolism. This investigation can detect cardiac thrombus or an atrial myxoma

KEY POINTS
Signs and symptoms of acute limb ischaemia – six Ps:
• pain
• pulseless
• pallor
• paraesthesia
• perishingly cold
• paralysis.



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