Upper Limb Ischemia, Acute

Cold Hand

Step 1: View clinicals

A 50 year old woman presents with pain and numbness of her left hand for 3 hours. These symptoms started abruptly, and have worsened over time. On close questioning, she reveals a history of recurrent palpitations for many years, which has not been investigated. Her medical, surgical, and family histories are unremarkable.

Step 2: Order all relevant investigations

CT Arteriogram L/Arm

The CT Arteriogram of the left subclavian artery shows pristine vessels up to the bifurcation of the brachial artery, at which point there is an acute cutoff, with a lack of contrast beyond that point.


The ECG shows an irregularly irregular rhythm, with a rate of 98 bpm. The baseline is irregular and P waves are absent. The QRS complexes, T waves and QT segments are normal.


The echocardiogram shows an ejection fraction of 68%. There is no evidence of valvular defects, intramural thrombus, aortic root pathology, vegetations or wall motion abnormalities.

Inherited Thrombophilia Screen

You realize that inherited thrombophilia screening is probably not indicated here.

Step 3: Select appropriate management

Systemic Thrombolysis
Start Heparin stat
Start Warfarin stat

Score: ★★☆