Case 7: Petechiae
Medical Mystery Case 7: Foot Petichiae
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An elderly lady is sent in from a nursing home for a “heel pressure sore”. The image is of the top of her foot. There are no other petechiae. In addition to what you see there was an area or ecchymosis on the heel that looked more like dry gangrene than a pressure sore. There was no edema and her feet were about the same temperature, but with decreased pulses on the involved side. What do you think could be going on here?
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ANSWER:
If the petechiae were symmetric you would think thrombocytopenia, right? But they were only on one side and her platelet count was normal. She had a duplex of the arterial and venous systems that showed complete thrombosis of both the arterial AND venous systems. She was treated with heparin and both arterial and venous embolectomy and the leg was saved. The vascular surgeon was surprised that the leg was not cold initially given the severity of the thromboses, but postulated that the DVT somehow was relatively protective in the setting of such a severe arterial thromosis.
Excerpt from “Quick Essentials“
ARTERIES: (Also see Trauma section)
ABI?s: Ankle/Brachial Index: 87. ABI: >.9: nl, <.5: severe, <.3=rest pain
Time: warm/cold ischemic time (90%save ) = 6/12h, 30h for finger
Hard signs: Pain, Parasthesias > Pallor, Poikylothermia, Pulseless,
Soft signs: pulse difference, capillary refill >2, duplex flow not triphasic, abnl ABI
Aneurysm: u post procedure: thrill, mass.
Rx: UTZ guided compression, thrombin, OR
Arterial——–Occlusion : Neuro Sx: numb, pain, weak. Flow Sx: cool, CR>2, pale.
W/u: Duplex, CT for AAA, Angio. Emboli: EKG, Echo. ABI. Lab: CPK/rhabdo
Rx: ASA, heparin(bolus 5-10,000 units), OR if no rigor mortise. NO: tPA
Blue toe: Emboli(heart,chol,aneurysm,Afib), Heme(^RBC,DIC), ischemia, vasculitis