2 Before the Exam… Obtain history Acute vs. Chronic symptoms Distribution of symptomsLevel(s) of extremity pain, etc.Aggravating, Relieving factorsActivity/rest, elevation/dependenceCo-morbid conditions, vitals
13 Clinical Scenario #1Routine 5pm ED consult for cellulitis.
14 Clinical Scenario #1 Routine 5pm ED consult for cellulitis. You see before leaving within your hrsOn arrival, 78yo male w/ DM, CAD, +tobaccoAlso, hx of “irregular HR” with INR of 1.1Rt foot cooler than Lt, no palp Rt DP or PTAcute onset severe pain started 3hrs agoEmbolectomy and anticoagulationDon’t forget fasciotomy
15 Clinical Scenario #2New consult for non-healing ulcer, evaluate for peripheral arterial bypass.
16 Clinical Scenario #2New consult for non-healing ulcer, evaluate for peripheral arterial bypass.Obese 63yo M dialysis w/ DM, HTNLegs down in chair, severely edematousAdvised to elevate and compression garments, but does not b/c uncomfortableNon-tender medial malleolar ulcer x3 wkB/L DP and PT are palpable
17 Clinical Scenario #3 Stat consult to 3A for r/o compartment sx. 39yo F s/p cardiac cath via L radial arteryCath performed for cough, was normalAfter sheath removed, arm doubled in sizeNurses want to know when pt going to OR
18 Clinical Scenario #3 Direct pressure applied, bleeding ceased Stat consult to 3A for r/o compartment sx.39yo F s/p cardiac cath via L radial arteryCath performed for sneezing, found normalAfter sheath removed, arm doubled in sizeDirect pressure applied, bleeding ceasedPalpable distal pulses were appreciatedNeurovascular exam intact w/ serial examsArm elevated to facilitate venous return
19 Berger’s Pet PeavesNo overnight pre-op IVF unless dehydration established or elderly pt AND afternoon caseReglan for N/V unless obstruction, espec DMZofran ONLY if nausea refractory to ReglanOnly attg name on consents except as witnessResidents can, however, sign blood consentsSCD’s for AAA’s only (NOT CEA’s, bypasses, etc)Vaseline gauze, NEVER iodoform gauzeDo NOT elevate extremities after access casesIncreases steal symptoms and neuropathyPeri-op edema will resolve, heart level adequateDextran x24hrs for all CEA’s EXCEPT Berger’s