Peripheral Vascular Disease

Arterial occlusion and venous disease side by side: the six P’s, how to tell a cold leg from a swollen one, and which one has hours to be saved.

CEN Content Outline, Cardiovascular Emergencies I. Arterial and venous problems present in opposite ways, and confusing them costs a limb.

Acute Arterial Occlusion

Blood is not getting to the limb. Usually an embolus — often from atrial fibrillation — or a thrombosis on top of existing disease, or trauma.

The six P's

• Pain — sudden, severe, out of proportion. • Pallor. • Pulselessness. • Paresthesia. • Paralysis. • Poikilothermia — the limb is cold. Pain, pallor and pulselessness come first. Paresthesia and paralysis are late and mean nerve and muscle are dying; a limb that has lost motor function has hours at most.

What to do

• This is time-critical. Vascular surgery is called on suspicion, not after imaging. • Mark where pulses are or are not, with a Doppler if they cannot be palpated, and re-check on a schedule. • Keep the limb at or slightly below heart level. Do not elevate — it reduces perfusion further. • Keep it warm passively, but no direct heat to an ischemic limb: the tissue cannot feel it and will burn. • Anticoagulation, usually heparin, as ordered. • Nothing by mouth — this patient is probably going to theatre or to interventional radiology. • After reperfusion, watch for compartment syndrome and for rhabdomyolysis with hyperkalemia.

Chronic Arterial Insufficiency

For contrast: intermittent claudication (pain with walking, relieved by rest), pain worse with elevation and relieved by dependency, hairless shiny skin, thick nails, cool limb, weak pulses. Ulcers are on the toes and pressure points, punched out, pale, and painful.

Venous Disease

Chronic Venous Insufficiency

Aching, heavy legs worse at the end of the day and relieved by elevation. Edema, brown haemosiderin staining, and ulcers at the medial malleolus that are shallow, irregular, wet and relatively less painful. Treated with compression and elevation — the opposite of arterial management, which is why the diagnosis matters before compression stockings go on. Compression on an arterially insufficient limb causes damage.

Deep Vein Thrombosis

Unilateral leg swelling, warmth, redness, tenderness along the deep veins. Measure both calves — a difference is more useful than an impression. Risk factors follow Virchow triad: stasis (immobility, long travel, surgery), endothelial injury (trauma, catheters), and hypercoagulability (malignancy, pregnancy, oestrogen, inherited thrombophilia, COVID). • D-dimer is useful to rule out in a low-risk patient; it is not useful to rule in, because it rises in infection, trauma, surgery, pregnancy and malignancy. • Duplex ultrasound is the diagnostic test. • Treatment is anticoagulation. The reason it matters in the emergency department is not the leg, it is the lung. See the chapter on thromboembolic disease.

Nursing Priorities

• Cold, pale and pulseless is a surgical emergency. Warm, red and swollen is a clot that needs a scan. Do not let one be treated as the other. • Document pulses with a consistent method and a time, so that "diminished" three hours later means something. • Never apply compression to a limb until arterial supply is known. • Ask about atrial fibrillation and anticoagulation adherence in any sudden cold limb — a missed dose is a common story. Topic list from the CEN Examination Content Outline effective July 2026 (BCEN, public document). This chapter was written for this app as study material and is not from any BCEN course.

Peripheral Vascular Disease