Venous gangrene: Difference between revisions
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===Others=== | ===Others=== | ||
*Cellulitis | *[[Cellulitis]] | ||
*Lymphedema | *[[Lymphedema]] | ||
*Venous valvular insufficiency | *Venous valvular insufficiency | ||
*Superficial thrombophlebitis | *[[Superficial thrombophlebitis]] | ||
*Arterial embolism | *[[Arterial embolism]] | ||
*Diabetic ulcer | *[[Diabetic ulcer]] | ||
*Wet/gas gangrene | *Wet/gas [[gangrene]] | ||
==Workup== | ==Workup== | ||
Revision as of 07:46, 30 December 2014
Background
- Massive iliofemoral or IVC occlusion with patent arteries
- Extensive vascular congestion and venous ischemia
- Involves superficial collateral veins
- 40-60% of phlegmasia cerulea dolens with capillary involvement progress to venous gangrene
Clinical Spectrum of Venous Thromboembolism
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
Only 40% of ambulatory ED pts w/ PE have concomitant DVT
Risk Factors
- Age 50-60s
- Malignancy (over half)
- Thrombophlebitis migrans
- Acquired hemolytic anemia due to cold-antibodies
- Typical risk factors for DVT (pregnancy, surgery, trauma, hypercoagulable syndrome)
- Idiopathic
Clinical Features
- Limb pain
- Severe edema
- Cyanosis
- Blistering and extravasation
- Purplish black well-circumscribed areas
- Superficial gangrene and necrosis
- Arterial patency
- Not reversible (vs. phlegmasia cerulea dolens and alba dolens are)
- Fluid sequestration and circulatory shock
Differential Diagnosis
Clinical Spectrum of Venous Thromboembolism
Clinical Spectrum of Venous thromboembolism
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]
Others
- Cellulitis
- Lymphedema
- Venous valvular insufficiency
- Superficial thrombophlebitis
- Arterial embolism
- Diabetic ulcer
- Wet/gas gangrene
Workup
- Clinical diagnosis
- Duplex US
- Contrast venography
- MRV
Management
- Interventional radiology consult for emergent catheter-directed thrombolysis
- Vascular surgery consult for thrombectomy
- Steep limb elevation
- Fluid resuscitation (PRBC)
- Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
- Thrombolytic: Alteplase (1mg/min to total of 50mg) distal to thrombus
Disposition
- Admit
See Also
External Links
Sources
- ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
- ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
- Dardik A. (2014, Feb 25). Phlegmasia Alba and Cerulea Dolens. eMedicine. Retrieved 12/21/2014 from http://emedicine.medscape.com/article/461809-overview.
- Sutton RA. Venous gangrene. Br Med J. 1966; 1(5501):1465-1466.
- Ross, JV, et al. Gangrene of lower extremity secondary to extensive venous occlusion. Circulation. 1961; 24: 549-556.