[brithenurse]

scenario: a patient you are looking after has had a bi-femoral insitu graft...you were able to check his dorsalis and post tibial pulses on arrival, however 2 hours later you can't find the pulses in one of his feet...
What do you do next?

[maolin]

I'm still a student, so I may be way off, but thought I'd take a stab at it anyway. Valuable learning activity

Assess pulses w/ doppler and if negative call the doc. Could have thrown a clot and in danger of loosing limb, therefore emergency situation. (?)

How did I do?

[Spatialized]

I'm like Maolin(above), only a student but I'll stab at it too...

1. check cap refill warmth, pallor, sensation in legs to see if they're intact...have seen patients whose pedal pulses are very weak, but they are actually perfusing well because the pulse is either still there or the have devent collateral circualtion (like in a chronic situation).

2. get a doppler and search like heck for any pulse in the LE that you can find. check all the spots to see where the deviation may be...pop., femoral etc. (pt. still has pulse right...?)

3. call the docs.

may have thrown a clot, I'd be checking for resp. distress, altered LOC etc. as well.

just my 2 bits worth,
Tom

[lady_inred]

Think this is an emergency situation,so call the doctor,don't delay!!!!You're through assessing already,so time to implement,right???? Well,i don't know,but this is what i feel is right to do....tell me if im wrong,im interested to know!

Originally Posted by brithenurse

scenario: a patient you are looking after has had a bi-femoral insitu graft...you were able to check his dorsalis and post tibial pulses on arrival, however 2 hours later you can't find the pulses in one of his feet...
What do you do next?

[JiffyGriff]

They may have FORMED a clot, but they haven't THROWN it yet until they are exhibiting signs of pulmonary embolism.......which are what...?? Respiratory distress, decreased breath sounds on affected side, decreasing O2 sats, an impending sense of doom related to hypoxia, and possible cyanosis.

But we're not quite there yet.....so what do you do about the possible formation of a clot in the leg there........check for signs of circulation which you've already started doing.....these are pulses, cap refill, numbness/tingling, warmth or cold of extremety, if you can't feel the pulses then yes check with doppler.......if you can't find them with the doppler call the doc immediately because something needs to be done, if there are no pulses the tissue in that extremity is dying.

Say you can hear the pulses though.......ok so how do we find out if there's a clot in there......check homan's sign maybe??? remember that one, check for any areas of redness or swelling, check for a line of demarcation, check for any hotspots.

So all of our evidence points to there being a formed clot, and we can hear pulses with the doppler, what do you do........tell the patient not to get out of bed, keep the leg straight, don't move it unless necessary......then go call the doc with the findings...........don't wait to call the doc.......thrombolytic therapy needs to be started within 3 hours of clot formation to be effective.......that is if they opt to use it or it's not contraindicated...........oh yeah......DON'T MASSAGE THE LEG TO RELIEVE PAIN.

So back to worst case, the pt. actually threw the clot and has a PE......what do you do then.........this: sit patient in high fowlers, start O2, have someone get a crash cart ready in case.......this pt. could code easily, get ahold of the doc to see what will happen from there........remember thrombolytics only effective within 3 hours.......PE's have high mortality rate and need to be taken care of STAT.

so that's what all of you were thinking in your minds right......

[maolin]

Pt can throw a clot (emboli) distal to the site as well, leading to artial occlussion downstream in a smaller vessel, rather than causing a PE. This would block bloodflow and eliminate pulse and circulation to that area.

For example, if the graft site is at the femoral artery, the bloodflow goes down the calf toward the feet. If a clot (thrombus) forms at the graft site and is dislodged (now an embolus), it will travel through the artery until it can no longer fit, thus lodging and cutting off distal circulation. In this case, s/sx would be no pulse, cool to touch, numbness, eventual tissue necrosis. In this case, it's unlikely the pt will experience respiratory distress as the clot isn't going to make it into venous circulation.