A 45-year-old man presents with a 2-day history of painful, pale, cold left foot. He has atrial fibrillation and did not take his anticoagulants. On examination, the foot is mottled with absent dorsalis pedis and posterior tibial pulses. Capillary refill is 8 seconds. Sensation is reduced but motor function is intact. What is the immediate next step in management?

• A Perform CT angiography to confirm the site of embolism
• B Administer intravenous unfractionated heparin and arrange urgent embolectomy ✓
• C Start intravenous streptokinesis over 24 hours
• D Obtain duplex ultrasound to assess runoff vessels

Explanation

This patient has acute limb ischemia secondary to a likely cardiac embolus from atrial fibrillation. With viable limb (intact motor function, some sensation), immediate anticoagulation with heparin followed by surgical embolectomy is standard. CT angiography delays definitive treatment. Thrombolysis is considered for subacute thrombosis in situ or when surgery is not immediately available. Duplex ultrasound is not indicated as the diagnosis is clinical and pulse examination is sufficient.

Reference: Rutherford's Vascular Surgery and Endovascular Therapy, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.