Thread by @PanktiMehta24

It's 🥶 & we're coming across many cases of peripheral ischemia/gangrene

🔢The semiology of seizures is what we are all taught, but gangrene is another condition where history is the king 👑

🔁It's essentially a demand≠supply mismatch

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The 📝 goes on & so that we can save ⏳ & 💰 on the tests, I like to broadly divide the pathology into:

1️⃣Luminal: atherothrombosis, thrombosis (APLA, DIC), cryofibrinogenemia

2️⃣Vessel wall: vasculitis (ANCA, PAN, SLE),vasculopathy (scleroderma spectrum)

3️⃣External compression

Q1️⃣: How was the onset?

🐌Insidious onset, gradual progression is the most common

➡️peripheral vascular disease

➡️most vasculitides

➡️vasculopathy

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⚡There are very few causes for bolt in the blue, acute gangrene with maximal involvement at the onset

➡️Cryofibrinogenemia (essential, post infective, autoimmune)

➡️Embolic (atheroembolic, infective endocarditis)

Now before we move ahead,

Progression of ischemia means an increase in the area of involvement and NOT further blackening of the same area

So mark the demarcation line on Day1️⃣!!

Q2️⃣what are the associated features with #gangrene~most important to narrow down your differentials & prevent ordering a gamut of investigations

1️⃣ Old age, long standing DM/HTN, history of CVA/CAD➡️ atherothrombosis

2️⃣ Young♀️, recurring pregnancy 🤰losses, CVA➡️ #APlagueTale

3️⃣ skin infarcts, nodules, skin ulcers, mononeuritis multiplex ➡️ vasculitis
(Also ask for specific features of ANCA associated #vasculitis, polyarteritis nodosa, #lupus, Sjogren, hepB/hepC)

4️⃣ #Raynaud's phenomenon, digital tip ulcers, pits➡️ vasculopathy (SSc, MCTD, lupus)

5️⃣ 🏥 #ICU setting is another scenario wherein patients present with gangrene

⏩ Peripheral symmetric gangrene: hypotension, vasopressor use

⏩ DIC

⏩Post infective CAD/cryofibrinogenemia

⏩Cardiac emboli

👀 out for these!!

6️⃣ history of infection, dipping hands/feet in cold water, involvement of ears/nose, maximal involvement at onet➡️ #cryofibrinogenemia

7️⃣ Do screen for danger symptoms/signs of #malignancy

Q3️⃣ site of involvement?

🦵- peripheral vasc disease, buerger's

✋Hands- vasculopathy

Both 💪🦵- vasculitis

🥶Cold exposed- cryofibrinogenemia

Q4️⃣Don't forget to enquire about smoking 🚬!
Both active and passive!

Buerger's disease is quite common, lower limb predominant, associated with superficial thrombophlebitis.

🫠Last but not the least !!

Do not wait for the test reports for initiating treatment for peripheral ischemia!!💊 💉

It's alright to initiate a cocktail of drugs till the etiology is clear.... precious time needn't be wasted! ⏳

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