ABSENT OR DIMINISHED PULSE

Ask the following questions:

1. Is it in the upper or lower extremities? Diminished pulse in the upper extremities should suggest dissecting aneurysm, embolism, fracture, arteriovenous fistula, coarctation of the aorta, aortic aneurysm, thoracic outlet syndrome, and subclavian steal syndrome. Diminished pulse in the lower extremities should suggest embolism, fracture, arteriovenous fistula, peripheral arteriosclerosis, Leriche's syndrome, and coarctation of the aorta, as well as dissecting aneurysm. Diminished pulses in all four extremities would suggest shock or constrictive pericarditis.
2. Is it unilateral or bilateral? The presence of unilateral absent or diminished pulse should suggest dissecting aneurysm, embolism, fracture, arteriovenous fistula, some cases of coarctation of the aorta, aortic aneurysm, thoracic outlet syndrome, and subclavian steal if it is in the upper extremity. In the lower extremities, unilateral decrease in the pulse may be due to arteriosclerosis. Bilateral diminished pulses would suggest Leriche's syndrome, saddle embolism, dissecting aneurysm, and coarctation of the aorta if it is in the lower extremity, and if it is in the upper extremity it may also be related to a dissecting aneurysm and rarely arteriosclerosis.
3. Is it sudden in onset? The presence of a sudden onset in diminished pulse should suggest an embolism or dissecting aneurysm regardless of where the diminished or absent pulse may be. However, if it is just the lower extremities, it could be Leriche's syndrome as well. If all four extremities are involved, of course, it could be shock.

DIAGNOSTIC WORKUP

Routine tests include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, EKG, and chest x-ray. If there is a history of trauma, x-rays of the involved extremity or extremities should be done. If it is acute onset with fever, a blood culture should be done to rule out bacterial endocarditis. Because an acute onset suggests an embolism, a search for the embolic source should be undertaken. This would include serial EKGs and cardiac enzymes to rule out myocardial infarction, echocardiography to rule out a thrombus in the atrium or ventricle, and 24-hr Holter monitoring to rule out auricular fibrillation of the paroxysmal variety. A cardiologist should be consulted for further guidance in determining if there is an embolic source.

If there are transient ischemic attacks, four-vessel angiography should be done to determine if there is a subclavian steal. If a dissecting aneurysm is suspected, aortography is the diagnostic procedure of choice and this must be done without delay. Doppler studies are of assistance in diagnosing the peripheral arteriosclerosis regardless of where it is, but angiography will ultimately need to be done to determine the exact location of the blockage and whether surgery could be effective in alleviating the condition.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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