Acute Limb Ischemia

Definisi, Etiologi & Patofisiologi

Evaluasi
Ns. Rambu KlinisDwihasti,
Inanda & Kelas SKep
Perawat Pelaksana ICVCU
Managemen
Definisi Acute Limb Ischemia

Penurunan perfusi
tiba-tiba pd arteri
ekstremitas yg
menyebabkan
ancaman viabilitas
ekstremitas
 Etiologi acute limb ischemia

Acute arterial embolism: Scr relatif pd cabang arteri sehat tree

(arrhythmia, cardiomyopathy, sheath,
oklusi Percutaneous Transluminal
Artery )
Acute arterial thrombosis: Seblmnya ada penyakit pd
pcabangan arteri (atherosclerosis)

Acute traumatic ischemia:

 Insiden
Laki-laki > Wanita pd trombosis

Laki-laki = Wanita pd emboli

Ekstremitas atas < Ekstremitas bawah

Mortalitas = 7 - 29%
Iskemik Emboli Iskemik
Pato-fisiologi Trombosis
Akut Akut
Emboli dpt berasal dr jtg (MS dgn atrial fibrillation, MI dgn mural
thrombus) atau dilated diseased arteries (aneurisma aorta)
Atherosklerosis
Emboli tiba2 menyebabkan
menyumbat penyempitan
percabangan cabang arteri scr
arteri yg sehat progresif

Biasanya Mstimulus
menetap pd pbentukan
bifurkasi kolateral
arteri
Aliran
Aortic bifurcation melambat &
Iliac bifurcation permukaan
Femoral bifurcation kasar dpt
Popliteal trifurcation msebabkan
trombosis akut
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.
 Postgraduates

Severitas iskemik akut tgantung pd:

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

(kolateral tumbuh pd psn dgn
b) Lokasi obstruksi b.d jmlh pcabangan arteri preexisting chronic ischemia)
Oleh krn itu, emboli arteri
c) Luas obstruksi cenderung msebabkan gejala yg
tiba-tiba & iskemik severe
Aorta & common iliac One axial a. with limited collateral pathways
Semakin besar obstruksi yg tjd,
dibanding dgnsemakin bykarteri
trombosis
d) Lama kolateral yg hilang
Internal & external iliac Two axial aa. With better collateral potentials
Aliran distal pd obstruksi melambat. Jika kolateral tdk dpt me
For Example:
aliran drh pd area tsb, hambatan aliran drh akan menetap pd
Popliteal a occlusion (a
Superficial & deep femoral area distal pcabangan
Two axial arteri.
aa. With better Heparin
collateral hrs diberikan
potentials sedini
single axial a.) results in
mungkin severe ischemia, while
Popliteal artery One axial a. with limited collateral pathways posterior tibial occlusion
may be asymptomatic if
other leg arteries are
patent
Tibial arteries Three axial aa. with better collateral potentials
Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & 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
Evaluasi Klinik Iskemik Akut (Gambaran
Klinik)
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)

 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)
 Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut Inspeksi

5Ps warna:

Fixed Awal: pale

Pain: gejala
mottling & Lanjut: sianosis mottling fixed

+ sianosis mottling & sianosis

An area of
Pallor
Pale fixed cyanosis
surrounded by
reversible
Pulseless Reversible
mottling
mottling
Parathesia
Empty veins:
bandingkan dgn
Paralysis kanan (iskemik) &
kiri (normal)
 Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut Palpasi

5Ps
Pain: gejala

+ Femoral Popliteal

Pale

Pulseless Posterior tibial Dorsalis pedis

Palpasi pulsasi perifer, bandingkan dgn

Parathesia ekstremitas yg lain & beri tanda

Temperatur: ekstremitas teraba dingin dgn

Paralysis (bandingkan diantara ekstremitas kiri & kanan)

Slow capillary refilling setelah tekanan jari

 Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut Palpasi

5Ps Hilangnya fungsi sensori

Pain: gejala Dr mulai baal s/d anestesia

+ Progress dr kehilangan
sensori
Pale Sentuhan halus
Sensasi Vibrasi
Pulseless proprioreseptor
Nyeri dalam
Parathesia
Sensasi tekan
Late
Paralysis
 Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut Palpasi

5Ps Hilangnya fungsi motorik:

Pain: gejala MIndicates advanced limb threatening
ischemia

+ Late irreversible ischemia: Bengkak otot

Pale
Postgraduates
Pulseless
Otot telapak adlh yg pertama kali
terkena, di ikuti o/ otot tungkai
Parathesia
Mdeteksi kelemahan otot scr dini
Paralysis adlh sukar krn pgerakan jari2
dihasilkan yg utama o/ otot tungkai
 Postgraduates

Classes of Acute Ischemia

Clinical Findings Doppler Prognosis

Class Sensory Motor Arterial Venous

loss weakness signals Signals
I. Viable -ve -ve audible audible Not immediately
threatened

II.a Marginal Minimal No muscle Often not audible Salvageable if prompt

sensory loss weakness audible ttt (there is time for
threat angiography)
II.b Immediate Rest pain w Mild to Usually audible Salvageable with
threat sensory loss moderate not immediate ttt (no time
more than toes audible for angiography)

III.Irreversible Severe Paralysis w Inaudible Inaudible Not salvageable,

anesthesia muscle rigor permanent N. & muscle
damage , needs amputation
Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & 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

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

Management
Investigasi acute 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
 Investigasi acute limb ischemia
Arteriografi

Patients with high clinical probability of embolic 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
Popliteal embolism Lt. iliac embolism
silhouette Reversed meniscus sign Clot silhouette
 Treatment of acute limb ischemia
A Once diagnosed

Immediate anticoagulation with heparin to avoid clot

propagation
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 the
metabolic rate)
Maximum tissue oxygenation (oxygen inhalation)
Correct hypotension
Start treatment of other associated cardiac conditions (CHF, AF)
 Treatment of acute limb ischemia
B Catheter directed thrombolysis Agents used: Streptokinase,
Urokinase, tissue plasminogen
Indications: activator

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

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
 Treatment of acute limb ischemia
C Surgery

1- Acute embolism: Catheter embolectomy 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
Embolectomy
Following revascularization:
The sudden return of oxygenated blood to the acutely
ischemic muscles generates & releases oxygen free radicals
that causes cellular injury and severe edema

Compartment syndrome
& muscle necrosis

ttt

Fasciotomy
Longitudinal incision of the skin & deep fascia to release pressure over swollen muscles
 Amputation:

Done for irreversible ischemia with permanent tissue

damage (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
Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability
Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial
infarction & 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
The limb is described as having 5 Ps :
Pain, Pale, Pulseless, Parathesia, Paralysis

Investigations Doppler to 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
 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
 Pengkajian

Kemunculan penyakit (5P)

Keluhan pain/nyeri: Onset, durasi,
intensitas, lokasi
Pallor
Paresthesia
Paralysis
pulselessness
 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 terhadap
serangan jantung, stroke, jendalan darah, atau
amputasi.)
 Pengkajian

Pemeriksaan Fisik
Pulsasi
Warna dan temperatur
Kehilangan fungsi sensoris
Kehilangan fungsi motorik
 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
 Intervensi Keperawatan
Observasi keluhan nyeri
Observasi TTV
Observasi pulsasi
Hindari penekanan pd area yg sehat
Hindari temperatur yg berlebihan
Kolaborasi: analgesik, atasi
penyebab,pemeriksaan dopler-angiografi,
terapi trombolitik, tindakan bedah