DrVirgo
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13. A 35 year old man complains of an acute onset of right lower leg tenderness. He has been previously healthy and denies trauma or recent infection. He does have a history of high cholesterol levels, and is cureently taking medication to lower them. On examination, his right leg is cool, pale, and tender. No dorsalis pedis pulse is appreciated. Which of the following is the most appropriate next step in management?
A. Administer Warfarin
B. Administer heparin
C. Obtain an arterial angiogram
D. Perform a fogarty catheter embolectomy
E. Perform surgical embolectomy via a cutdown
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| ashfaque
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C
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| yasmeen
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C
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| DrVirgo
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No, actually I thought it was C as well, but the correct answer is B! -Administer Heparin.
Aren't heparin and warfarin for Venous clots?
This patient has an absence of the dorsalis pedis pulse, so arterial problem?
I'm stuck. 
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| DrVirgo
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Anyone know?
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| mazinger
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Well here is my perspective, this is a young patient who has had an arterial embolus/clot, perhaps he has a hereditary trombophillia or any hypercoagulable state. You need to start heparin right away to prevent further embolism or clotting.. Why not warfarins? take 2 to 3 days to start working and in the first days of therapy they produce a hypercoagulable state since they also block prot C and S synthesis (since they have a shorter half life yata, yata, yata)..
These both will work in arterial and venous circulations and salicilates as well...
Why not performing a clot removal? From my perspective its best to start anticoag treatment right away because you want to avoid further embolism, lets say "how would you feel if your patient with a hypercoagulable state developes a cerebral infarct while you were removing the clot of the leg?".
BTW with this last state I mean no offense, I just want to help but thats the logic thinking I used to pick heparin over removing the clot by any means....
Hope this helps and have fun... 
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| sarika
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They mentioned in the question that he's taking lipid lowering drug which is most probably a statin a side effect of which is rhabdomyolysis. As we know rhabdomyolysis can cause compartment syndrome like in this patient....how do we go forward...i qould say fasciotomy...but thats not in the choice...so i dont know. ..
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| SCI.AFTAB
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statins along with fibrosil can cause rabdo , but I have seen only a few cases.
Heparin is a good choice and as you know and in Mi we prescribe heparin withaspirin right away.
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| mammyQ
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Treatment for either thrombi or emboli in the setting of PVD is similar. Empirically initiate a heparin infusion with the goal of increasing activated partial thromboplastin time to 1.5 times normal levels. Acute leg pain correlated with a cool distal extremity, diminished or absent distal pulses, and an ankle blood pressure under 50 mm Hg should prompt consideration of emergent surgical referral.
So we will probably start with Heparin then surgery
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