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surgery.acute-limb-ischemia.core.v1PRODUCTION
surgery.acute-limb-ischemia.core.v1

Acute Limb Ischemia

vascularacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm ALI scope (<14d) — chronic limb-threatening ischemia routes to CLTI engine (2024 ACC/AHA/SVS PAD)

Inputs
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Actions
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Advance rule
Set
Advance when

symptom onset <14 days documented

Patient inputs (14)

Older patients more likely embolic from AF; alters revasc choice (2024 ACC/AHA/SVS PAD)

New AF (tachy-irregular) is the dominant embolic source (2024 ACC/AHA/SVS PAD)

Within 14 days defines ALI; <6h vs >6h alters reperfusion-injury risk (ESVS 2020)

CTA contrast gating + heparin/lytic adjustment (2024 ACC/AHA/SVS PAD)

Hyperkalemia from reperfusion / muscle necrosis (Rutherford III pre-revasc) (ESVS 2020)

Baseline coag before heparin; informs thrombolytic safety (2024 ACC/AHA/SVS PAD)

Heparin / lytic contraindication threshold; HIT screen if heparin exposure (2024 ACC/AHA/SVS PAD)

Defines anatomy + level of occlusion; DSA when CTA contraindicated (2024 ACC/AHA/SVS PAD)

Shock screens for systemic embolic shower / aortic occlusion (ESVS 2020)

Ischemic muscle necrosis marker; elevated lactate + tense muscle = Rutherford III (ESVS 2020)

Embolic vs thrombotic distinction alters revasc strategy (2024 ACC/AHA/SVS PAD)

Graft thrombosis vs native artery occlusion (STILE) (Weaver/Comerota 1996)

Thrombolytic absolute / relative contraindications (TOPAS) (Ouriel 1998)

CK >5000 suggests muscle necrosis; gates rhabdo / reperfusion injury management (ESVS 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningrutherford_iii_irreversible
    Rutherford III — paralysis + sensory loss + tense / non-compressible muscle + doppler silent venous + arterial; muscle is dead — reperfusion is LETHAL (Rutherford 1997)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrutherford_iib_threatened
    Rutherford IIb — motor deficit + sensory loss + audible venous but no arterial doppler — limb salvageable only with immediate revasc (Rutherford 1997)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghyperK_pre_or_post_revasc
    K >6.0 with EKG changes (peaked T, widened QRS) — pre-revasc from necrotic muscle / post-revasc from reperfusion (ESVS 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcompartment_syndrome_post_revasc
    Post-revasc tense compartment, pain with passive stretch, elevated CK, or measured delta-P <30 mmHg (DBP minus compartment pressure) (AAOS; McQueen 1996 PMID 8898137)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererutherford_iia_marginally_threatened
    Rutherford IIa — minimal sensory loss (toes only), no motor deficit, audible venous, inaudible arterial doppler (Rutherford 1997)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterutherford_i_viable
    Rutherford I — viable, no immediate threat, normal motor, doppler audible both venous + arterial (Rutherford 1997)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Acute limb ischemia — Rutherford-driven anticoagulation + revascularization (2024 ACC/AHA/SVS PAD; ESVS 2020)
axis: ali_rutherford_pathwaystep 1 - Step 1 — Immediate IV anticoagulation (all Rutherford categories) BEFORE imaging
Selected step "Step 1 — Immediate IV anticoagulation (all Rutherford categories) BEFORE imaging" — Acute limb ischemia suspected; no absolute heparin contraindication
  • heparin
    first line
    unfractionated_heparin
    Bolus 80 U/kg IV; infusion 18 U/kg/h titrated to aPTT 1.5-2.5x control (60-80 sec) • IV • continuous infusion
    triggers: ALI_suspected, no_active_major_bleed, platelets_above_50
    UFH first-line immediately on suspected ALI (Class I) — propagates clot less; rapid titration; reversible (protamine). 2024 ACC/AHA/SVS PAD Section 8 (PMID 38752899); ESVS 2020 ALI Recommendation 7 (PMID 31899099)
    rxcui 5224
  • bivalirudin
    contraindication substitute
    direct_thrombin_inhibitor
    0.75 mg/kg bolus then 1.75 mg/kg/h • IV • continuous infusion
    triggers: HIT_history, heparin_contraindicated
    Alternative when HIT history / current; direct thrombin inhibition not requiring AT-III; renally cleared so dose-reduce CrCl<30 (2024 ACC/AHA/SVS PAD)
    rxcui 60819

ed playbook — drug actions (4)

  1. 1. heparin IV
    Bolus 80 U/kg + infusion 18 U/kg/h titrated to aPTT 1.5-2.5x • IV • continuous
    trigger: ALI suspected, no active bleed (2024 ACC/AHA/SVS PAD)
    Class I — start immediately on suspicion BEFORE imaging (PMID 38752899)
  2. 2. IV crystalloid
    500-1000 mL bolus then maintenance • IV • bolus then maintenance
    trigger: Pre-revasc, contrast load planned (ESVS 2020)
    Contrast nephropathy prevention + myoglobinuria volume support
  3. 3. fentanyl
    25-50 mcg IV q15min PRN • IV • q15min PRN
    trigger: Ischemic pain (ESVS 2020)
    Acute pain control awaiting revasc
  4. 4. alteplase CDT (only at IR/vascular center for Rutherford I-IIa)
    0.5-1.0 mg/h intra-arterial • intra-arterial catheter • continuous infusion 12-48h
    trigger: Rutherford I/IIa + viable limb + no lytic contraindication (2024 ACC/AHA/SVS PAD)
    TOPAS/STILE Class IIa for I-IIa (PMID 9545358; PMID 8911400)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Six Ps — Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (2024 ACC/AHA/SVS PAD); Sudden severe limb pain with cold/mottled extremity (ESVS 2020); New AF / recent MI with mural thrombus / prosthetic graft / mechanical valve (2024 ACC/AHA/SVS PAD).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Limb Ischemia** (surgery.acute-limb-ischemia.core.v1).
Phenotype framing: Distinguish ALI vs acute-on-chronic CLTI vs phlegmasia cerulea dolens (DVT) vs compartment syndrome vs acute aortic occlusion (saddle embolus) (ESVS 2020)
Scope: Confirm ALI scope (<14d) — chronic limb-threatening ischemia routes to CLTI engine (2024 ACC/AHA/SVS PAD)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute limb ischemia — Rutherford-driven anticoagulation + revascularization (2024 ACC/AHA/SVS PAD; ESVS 2020)** — step "Step 1 — Immediate IV anticoagulation (all Rutherford categories) BEFORE imaging".
1. heparin Bolus 80 U/kg IV; infusion 18 U/kg/h titrated to aPTT 1.5-2.5x control (60-80 sec) IV continuous infusion (unfractionated_heparin, first line) — UFH first-line immediately on suspected ALI (Class I) — propagates clot less; rapid titration; reversible (protamine). 2024 ACC/AHA/SVS PAD Section 8 (PMID 38752899); ESVS 2020 ALI Recommendation 7 (PMID 31899099)
2. bivalirudin 0.75 mg/kg bolus then 1.75 mg/kg/h IV continuous infusion (direct_thrombin_inhibitor, contraindication substitute) — Alternative when HIT history / current; direct thrombin inhibition not requiring AT-III; renally cleared so dose-reduce CrCl<30 (2024 ACC/AHA/SVS PAD)

Setting playbook (ed) — Recognize Six Ps; assign Rutherford category; start IV heparin within 30 min; STAT CTA + vascular surgery + IR consult; OR/IR within hours for Rutherford IIb-III (2024 ACC/AHA/SVS PAD)
3. heparin IV Bolus 80 U/kg + infusion 18 U/kg/h titrated to aPTT 1.5-2.5x IV continuous — ALI suspected, no active bleed (2024 ACC/AHA/SVS PAD) (Class I — start immediately on suspicion BEFORE imaging (PMID 38752899))
4. IV crystalloid 500-1000 mL bolus then maintenance IV bolus then maintenance — Pre-revasc, contrast load planned (ESVS 2020) (Contrast nephropathy prevention + myoglobinuria volume support)
5. fentanyl 25-50 mcg IV q15min PRN IV q15min PRN — Ischemic pain (ESVS 2020) (Acute pain control awaiting revasc)
6. alteplase CDT (only at IR/vascular center for Rutherford I-IIa) 0.5-1.0 mg/h intra-arterial intra-arterial catheter continuous infusion 12-48h — Rutherford I/IIa + viable limb + no lytic contraindication (2024 ACC/AHA/SVS PAD) (TOPAS/STILE Class IIa for I-IIa (PMID 9545358; PMID 8911400))

Non-pharmacologic actions:
- Limb in dependent position; do NOT elevate (worsens ischemia) (ESVS 2020)
- Keep warm but NO direct heat (skin burn risk in insensate limb) (ESVS 2020)
- NPO pending OR/IR (2024 ACC/AHA/SVS PAD)
- STAT vascular surgery + IR consult on arrival (2024 ACC/AHA/SVS PAD)
- Mark limb pulses with skin marker + serial reassessment (ESVS 2020)
- Foley if Rutherford IIb-III (rhabdo / myoglobinuria UOP monitoring) (ESVS 2020)

AVOID / contraindication checks:
- Lytic_absolute_contraindications_recent_stroke_intracranial_bleed_major_surgery_within_10d (2024 ACC/AHA/SVS PAD)
- Rutherford_III_no_reperfusion_proceed_to_amputation (ESVS 2020)
- Check_HIT_screen_at_5_to_14_days_of_heparin (2024 ACC/AHA/SVS PAD)
- Fasciotomy_threshold_delta_pressure_under_30 (AAOS / McQueen 1996 PMID 8898137)

Monitoring

Regimen monitoring:
- aPTT q6h during heparin titration (2024 ACC/AHA/SVS PAD)
- serial compartment exam q1h x 6h post revasc (ESVS 2020)
- K creatinine CK q4 to 6h post revasc x 24h (ESVS 2020)
- urine output target above 0.5 mL kg h with myoglobinuria prevention (ESVS 2020)
- ABI or duplex at 24h post revasc then 1 month (2024 ACC/AHA/SVS PAD)
- fibrinogen q6h during lysis hold if under 100 (TOPAS, Ouriel 1998)

Setting (ed) monitoring:
- Compartment exam q30-60min (ESVS 2020)
- aPTT 6h after heparin initiation (2024 ACC/AHA/SVS PAD)
- K, Cr, CK q4-6h if Rutherford IIb-III (ESVS 2020)

Follow-up plan: Long-term anticoagulation (DOAC or warfarin) if embolic source; antiplatelet + high-intensity statin if thrombotic; smoking cessation; vascular medicine follow-up; ABI / duplex at 1 month (2024 ACC/AHA/SVS PAD)
- Close-out criterion: secondary prevention plan in place

Monitoring phase: Serial compartment exam (fasciotomy threshold delta-P <30); CK / K / Cr / lactate q4-6h x 24h post-revasc; urine output + dipstick for myoglobinuria; aPTT q6h on heparin (ESVS 2020)

Disposition

Current setting: ed — Recognize Six Ps; assign Rutherford category; start IV heparin within 30 min; STAT CTA + vascular surgery + IR consult; OR/IR within hours for Rutherford IIb-III (2024 ACC/AHA/SVS PAD)

Disposition criteria:
- OR (vascular) emergent: Rutherford IIb (motor deficit, salvageable) -> embolectomy / bypass + fasciotomy (2024 ACC/AHA/SVS PAD)
- IR suite: Rutherford I-IIa -> CDT or PMT (2024 ACC/AHA/SVS PAD)
- OR (orthopedic / vascular): Rutherford III -> primary amputation (do not reperfuse necrotic muscle) (ESVS 2020)
- ICU post-revasc: all Rutherford IIb-III after procedure (ESVS 2020)

Escalation triggers (move to higher acuity):
- Progression I -> IIa -> IIb -> III on serial exam -> upgrade OR/IR urgency (Rutherford 1997)
- New motor deficit -> Rutherford IIb -> STAT surgical embolectomy + fasciotomy (2024 ACC/AHA/SVS PAD)
- Tense compartment + pain on passive stretch -> compartment syndrome -> fasciotomy (AAOS)
- K >6.0 with EKG changes or tense necrotic muscle pre-revasc -> hyperK protocol; consider primary amputation for Rutherford III (ESVS 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Rutherford III — paralysis + sensory loss + tense / non-compressible muscle + doppler silent venous + arterial; muscle is dead — reperfusion is LETHAL (Rutherford 1997)
- [LIFE_THREATENING] Rutherford IIb — motor deficit + sensory loss + audible venous but no arterial doppler — limb salvageable only with immediate revasc (Rutherford 1997)
- [LIFE_THREATENING] K >6.0 with EKG changes (peaked T, widened QRS) — pre-revasc from necrotic muscle / post-revasc from reperfusion (ESVS 2020)

Citations

- 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (Gornik 2024) + ESVS 2020 Clinical Practice Guidelines on Management of Acute Limb Ischaemia (Bjorck 2020) [PMID:38752899](https://pubmed.ncbi.nlm.nih.gov/38752899/)
- Cited evidence (PMID 38743805) [PMID:38743805](https://pubmed.ncbi.nlm.nih.gov/38743805/)
- Cited evidence (PMID 31899099) [PMID:31899099](https://pubmed.ncbi.nlm.nih.gov/31899099/)
- Cited evidence (PMID 9308598) [PMID:9308598](https://pubmed.ncbi.nlm.nih.gov/9308598/)
- Cited evidence (PMID 9545358) [PMID:9545358](https://pubmed.ncbi.nlm.nih.gov/9545358/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (Gornik 2024) + ESVS 2020 Clinical Practice Guidelines on Management of Acute Limb Ischaemia (Bjorck 2020) — PMID:38752899
  • Cited evidence (PMID 38743805) — PMID:38743805
  • Cited evidence (PMID 31899099) — PMID:31899099
  • Cited evidence (PMID 9308598) — PMID:9308598
  • Cited evidence (PMID 9545358) — PMID:9545358