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Integ Fall 2024 > Arterial & Venous Insufficiencies > Flashcards

Arterial & Venous Insufficiencies Flashcards

1
Q

What is an arterial insufficiency wound?

A

a wound that results from a lack of blood flow

occurs when there is some sort of trauma to an already ischemic limb

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2
Q

What is the etiology of arterial insufficiency?

A
  • trauma
  • acute embolism
  • diabetes mellitus
  • RA
  • Thromboangitis (Buerger’s disease)
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3
Q

What is the difference between arteriosclerosis and atherosclerosis?

A

Arterio: thickening/hardening of arteries
Athero: narrowing of arteries (plaque build up)

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4
Q

What is Intermittent Claudication and how does it occur?

A

Activity-specific discomfort due to local ischemia
- pain normally stops w/in 1-5 minutes of rest

  • about 50% stenosis to occur
  • pain is described as cramping, burning, fatigue
  • usually Iliofemoral artery obstruction or Infrapopliteal artery obstruction
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5
Q

What is ischemic rest pain?

A
  • more significant arterial disease
  • burning pain exacerbated with elevation and relieved by dependency position
  • increasing tissue O2 demand can fatally upset the balance b/w O2 supply and tissue demand which causes an ulcer
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6
Q

What is the chain of events for an AI ulcer?

A

Arterial insufficiency -> intermittent claudication -> ischemic rest pain -> ulcer

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7
Q

What is gangrene?

A
  • when O2 supply does NOT equal demand = cell death
  • lack of perfusion to tissues which leads to dead tissue

usually tips of fingers/toes

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8
Q

What is better: dry or wet gangrene?

A

DRY is better

  • wet = signs of infection
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9
Q

What are contributing factors to arterial disease?

A

Diabetes*
- calcification
- microvascular disease
- hyperglycemia (impairs all phases of healing & decreases infection fighting ability)
- A1c level

*causes all of the above to occur

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10
Q

What is the pain of arterial wounds?

A
  • severe unless masked via neuropathy
  • increases with elevation
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11
Q

What is the position of arterial wounds?

A
  • primarily LE
  • distal toes
  • dorsal foot
  • areas of trauma
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12
Q

What is the presentation of arterial wounds?

A
  • regular appearance
  • may conform to precipitating trauma
  • pale granulation tissue (if present)
  • black eschar (dead tissue over wound)
  • gangrene
  • little to no drainage
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13
Q

What is the periwound & extrinsic tissue like around arterial wounds?

A
  • thin, shiny, anhydrous (dry)
  • loss of hair growth
  • thickened, yellow nails
  • pale, dusky or cyanotic skin
  • dependent rubor
  • unusual edema (could indicate VI or CHF)
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14
Q

How are the pulses in arterial wounds?

A
  • decreased or absent pedal pulses
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15
Q

How is the temperature of arterial wounds?

A
  • cool/decreased
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16
Q

What are the characteristics of arterial insufficient wounds?

A
  • begin small and shallow
  • round and regular or conform to trauma
  • any granulation tissue will be pale or grey
  • necrotic tissue desiccated with black eschar
  • minimal or no wound drainage, even with infection
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17
Q

How can PT’s test for AI?

A
  • Pulses
  • Doppler ultrasound
  • ABI
  • Rubor of Dependency
  • Capillary Refill
  • Venous Filling Time
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18
Q

Why would you do a doppler ultrasound test?

A
  • decreased or absent pulses
  • helpful in assessing arterial patency

supine position

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19
Q

Why would you do an ABI?

A

SHOULD BE FIRST LINE OF TESTING
- decreased/absent pulses
- signs/symptoms of AI
- history of PVD

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20
Q

What do the values of the ABI mean?

A

1.1-1.3: vessel calcification (too high)
.9-1.1: normal
.7-.9: mild to moderate arterial insufficiency
.5-.7: moderate arterial insufficiency; intermittent claudication
<.5: severe arterial insufficiency; rest pain; NO COMPRESSION
<.3: rest pain and gangrene

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21
Q

What are some reasons to do a rubor of dependency test?

A
  • unable to tolerate ABI, ABI >1.1, diabetes, or vessel calcification
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22
Q

What does Rubor of Dependency do?

A
  • indirectly assesses LE arterial blood flow

blood pools in the foot

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23
Q

How do you perform a Rubor of Dependency?

A

1) elevate LE 60 degrees for 1 minute
2) note foot color (on sole of the foot): little or no color change is normal
3) Return leg to surface and note time to return to normal color: normal is 15-20 seconds

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24
Q

How do you interpret the results of a Rubor of Dependency test?

A

Pallor after __ sec of elevation:
- 45-60: mild AI
- 30-45: moderate AI
- w/in 25: severe AI

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25
Q

Why would you do a capillary refill test?

A
  • digital ulcer
  • abnormal doppler ultrasound or ABI

done AFTER putting on compression bandaging for venous ulcers
- reliable indicator of surface arterial blood
- normal refill time is <3 seconds

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26
Q

Why would you do a venous filling time test?

A
  • unable to tolerate ABI, ABI >1.1, diabetes or vessel calcification
  • suspected concomitant VI
  • prolonged time is predictive of arterial insufficiency
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27
Q

How do you perform a venous filling time test and how are the results interpreted?

A

1) patient in supine, note superficial veins on dorsal foot
2) elevate limb to 60 degrees for 1 minute
3) lower limb to dependent position, note time for veins to refill

Results:
<5 secs: VI
5-15 secs: normal
>20 secs: AI

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28
Q

What are some medical tests for blood flow?

A
  • plethysmography
  • duplex scanning
  • transcutaneous oxygen monitoring (TCOM)
  • Toe pressures
  • Arteriography (dye scan)
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29
Q

What are some medical interventions for AI?

A
  • Risk factor management: cholesterol, BP, diabetes
  • Prescription drugs: for pain and circulation
  • Sympathetic block: eliminates CNS control of vasoconstriction (stays dilated)
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30
Q

What are some surgical interventions for AI?

A
  • debridement
  • revascularization
  • percutaneous balloon angioplasty
  • amputation
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31
Q

What determines prognosis of AI wounds?

A
  • size and depth: superficial/smaller heal faster
  • local tissue perfusion: ABI >.5, toe pressure > 30mmHG not great
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32
Q

What are some ways PT’s can help manage AI wounds?

A
  • coordinate care with patients, caregivers, and other disciplines
  • address etiology and modifiable risk factors
  • limb protection ed: from trauma, chemicals, heat/cold, open wounds
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33
Q

What are some things to consider when it comes to local wound care in AI wounds?

A
  • protect surrounding skin: moisturize dry skin, reduce friction, provide padding to ischemic tissue
  • address wound bed: choose appropriate dressing, debride necrotic tissue if appropriate
  • maximize circulation: avoid compression, choose footwear to accommodate bandages and decrease stress on tissues
  • educate patient/caregiver
34
Q

What are some precautions in treating AI wounds?

A
  • avoid compression and compression dressings (decreases BF)
  • PT has limited value in patients with low ABI w/o revascularization
  • reassess POC if wound doesn’t progress w/in 2-6wks
  • avoid sharp debridement of dry, eschar-covered, uninfected ulcers in patients w/ low ABI
  • gangrenous tissue must be removed surgically
35
Q

When would you refer a patient for further testing with AI?

A
  • invalid ABI (cant compress arteries)
  • wounds that fail to progress
  • suspected infection
  • exposed capsule or bone
36
Q

What are some things PT’s can do with patients with AI?

A
  • gait-training and mobility
  • aerobic conditioning
  • resistive exercise
  • stretching and positioning (avoid excessive hip & knee flexion)
37
Q

What are some modalities and physical agents for AI?

A
  • therapeutic heat
  • E-stim
  • hyperbaric O2 chamber
  • negative pressure wound therapy
38
Q

What are some footwear options for those with AI?

A

Temporary:
- cast shoes
- rocker bottoms
- enclosed shoe

Permanent:
- extra depth toe box
- adequate length
- soft/flexible
- specialized if needed via orthotist

39
Q

What is venous insufficiency?

A
  • condition where the veins, particulary in the LE, have difficulties sending blood back to the heart
  • Prevalence is up to 35%
  • 30% VI ulcers need 6+ months to heal
  • 91% of venous ulcers can heal with conservative management

often also have AI

40
Q

How does blood return back to the heart?

A
  • calf muscle pump
  • respiratory pump
  • valves
41
Q

What is the main etiology for VI?

A
  • sustained venous hypertension
42
Q

What are some common causes of venous HTN?

A

Vein dysfunction:
- incompetent superficial and perforating veins
- bicuspid valves fail to close
- valve damage

Calf muscle pump failure

or combo of both

43
Q

What vein, if reflux occurs, increases odds of a VI ulcer by 7x?

A

Great saphenous vein
- incompetence occurs in 25-50% of VI ulcers

most VI appears to be caused by reflux

44
Q

What are the two theories for the mechanism by which venous hypertension causes tissue damage?

A

White blood cell theory:
- congestion & distension is caused by venous hypertension
- this causes WBC’s to come to area increasing pressure
- WBC’s become trapped & start inflammatory response
- ulcer forms from hypoxia

Fibrin cuff theory:
- distension causes leaking veins & causes fibrinogen to leak out causing edema
- fibrinogen forms to fibrin & attaches to capillary walls forming a cuff (prevents O2 & nutrient exchange)
- causes an ulcer

45
Q

What are some risk factors for VI ulcer development?

A
  • vein dysfunction
  • valve damage
  • calf muscle failure: calf weakness/paralysis, decreased DF, prolonged standing, incompetent valves
  • trauma
  • previous VI ulcer
  • advanced age
  • obesity
  • diabetes
46
Q

How is diabetes a risk factor for VI ulcer development?

A
  • increased risk of microvascular disease and impaired immune response
  • impairs all 3 phases of wound healing
  • more sustained hyperglycemia, greater adverse affect on wound healing
47
Q

What is the pain of a VI ulcer?

A
  • mild to moderate unless masked by neuropathy
  • decreases with elevation/compression
48
Q

What is the position of a VI ulcer?

A
  • medial malleolus
  • medial leg
  • areas of trauma
49
Q

What is the presentation of a VI ulcer?

A
  • irregular shape
  • fibrous, glossy coating
  • red, ruddy wound bed
  • copious drainage
50
Q

What does the periwound & extrinsic tissue look like with VI ulcers?

A
  • edema
  • dermatitis and cellulitis
  • hemosiderin staining
  • lipodermatosclerosis
51
Q

What are the pulses like with VI ulcers?

A
  • normal or decreased due to edema or concomitant AI
52
Q

What is the temperature of a VI ulcer?

A
  • normal to mild warmth
53
Q

What are some tests for VI?

A
  • clinical assessment for DVT
  • ABI
  • Trendelenburg test
  • doppler
  • venous filling time
  • circumferential measurements
54
Q

Why would you do a clinical assessment for DVT?

A
  • lower leg ulcer
  • lower leg edema
  • suspected DVT

scoring a 3 or higher means hold treatment and consult physician

55
Q

How do you do the Trendelenburg test and why would you do it?

A
  • used to identify incompetence and differentiate b/w which veins

1) supine, leg in 45 degrees elevation for 1 minute
2) note venous distension
3) Tourniquet to distal thigh
4) stand upright and note time for superficial venous distension
5) repeat w/o tourniquet

56
Q

How do you interpret the results of the Trendelenburg test?

A

Tourniquet on: <20 sec = deep or perforator vein incompetence

Tourniquet off: <10 sec = superficial vein incompetence

57
Q

What do circumferential measurements do?

A
  • objectively measure the size of limbs with edema
  • determines effectiveness of compression and therapies
58
Q

What are some medical tests for VI ulcer?

A
  • duplex ultrasonography
  • venography
  • doppler studies
59
Q

What are some management risk factors for VI ulcers?

A
  • cardiovascular disease
  • obesity
  • diabetes
60
Q

What are some pharmacological interventions?

A
  • fibrinolytics (improves healing)
  • topical agents (antimicrobial, steroids)
  • systemic antibiotics
61
Q

What are some surgical options for VI?

A

Vein surgery:
- ligation (tie off veins around ulcer)
- stripping (recession of varicosities)
- sclerotherapy
- SEPS procedure (subfascial endoscopic interruption of perforation veins)
- PAPS (percutaneous ablation of perforating veins)
- stents

62
Q

What is the prognosis of VI ulcers?

A
  • average time is 8 weeks
  • smaller ulcers = 5-7 weeks
  • larger ulcers = 10-16 weeks

30-60% will heal within 3 months if treated with compression
check ABI and refer if not healing w/in 4 weeks

63
Q

How can PT help in the management of VI ulcers?

A
  • educate about etiology
  • inform risk factors for re-ulceration
  • edema control: positioning, exercise, compression
  • educate on guidelines
64
Q

What are some guidelines for those with VI ulcers?

A
  • control swelling
  • protect your feet and legs
  • live healthy
  • call a clinical if notice wound is getting bigger, draining more, smells, have increased swelling/pain, or detect a new wound
65
Q

What are some precautions in treatment of VI ulcers?

A
  • concomitant arterial disease (cannot compress if have AI)
  • allergic reactions (topicals and antibiotics)
  • inappropriate whirlpool use
66
Q

When would you refer a patient with VI for further testing?

A
  • patients scoring 3 or more on DVT prediction
  • ulcer fail to progress
  • suspected infection
  • bone scan/X-rays if exposed capsule or bone
  • atypical presentation of VI
67
Q

What is important when caring for a VI ulcer?

A

Protect surrounding skin
Address wound bed
- treat needs of the wound
- use periwound skin sealants
- choose absorptive
Enhance venous return
- compression
- edema prevention

68
Q

What are some interventions that can be done with those with VI ulcers?

A

ROM and strengthening exercises
- target ankle PF/DF
Aerobic exercise
Gait and mobility training
- positive influence on calf muscle/respiratory pumps weight loss, and blood sugar control

69
Q

What is compression therapy used for?

A
  • VI ulcers
  • lymphedema ulcers
70
Q

What are some benefits of compression therapy?

A
  • enhances calf muscle pump
  • improves venous return
  • decreases peripheral edema
  • reduces venous distension
  • increases tissue O2
  • protects limb from trauma
71
Q

What are some common ways to compress?

A
  • paste bandage
  • short-stretch bandage
  • multilayer compression bandage system
72
Q

What are some contraindications for compression?

A

ABI
- .5-.69 = cautious use of LOW compression
- <.5 = NO COMPRESSION
Acute infection
Pulmonary edema
Uncontrolled/severe CHF
Active DVT

73
Q

What is a paste bandage?

A

Gauze impregnated w/ zinc oxide, calamine, glycerin, and gelatin that hardens to a semi-rigid support
- worn for 1 week
- pt must be ambulatory

74
Q

What are some disadvantages of a paste bandage?

A
  • inability to shower
  • odor
  • clinicians must apply and remove
75
Q

What is a short stretch compression wrap and what are some disadvantages?

A

High working pressure, low resting pressure
- ambulatory & non-ambulatory patients

Disadvantages:
- prone to slippage
- pt’s must be able to re-apply

76
Q

What does a long stretch compression wrap do?

A

High resting pressure, low working pressure
- very elastic

77
Q

What do the different layers of a compression wrap do?

A

Inner layer:
- absorbs excess drainage
- provides padding
Middle layer:
- absorbs drainage
Outer 1-2 layers:
- increases pressure

stays better than short stretch

78
Q

What is a Circaid wrap?

A
  • removeable semi-rigid orthotic compression device
  • rows of nonelastic velcro straps provide sustained compression
  • easy to apply but expensive

daily wear required

79
Q

What are tubular bandages and the disadvantages?

A
  • off the shelf
  • allow for graduated compression

Disadvantages:
- generic shapes & sizes do not accommodate all patients
- bandages lose shape & compression in a short time

80
Q

What are compression garments?

A
  • used for long term management for edema reduction and control venous hypertension
  • require circumferential and limb length measurements
  • usually require donning aids
  • wear 24/7 except while sleeping and bathing
81
Q

What are the indications for class 0-4 of compression garments?

A

0: Non ambulatory patients (<20mmHg)
1: mild VI, VI w/ mild AI (20-30 mmHg)
2: moderate VI (30-40 mmHg)
3: severe VI (40-50 mmHg)
4: severe VI rarely required (>50 mmHg)

82
Q

What is most important when it comes to adherence to compression?

A

Education:
- closed but underlying pathology remains (must continue to wear compression garments)
- provide rationale for not wanting to go through healing an ulcer again
- risk of discontinuing compression (could get another ulcer and edema)
- veins are damaged and we CANNOT fix them damaged forever

Integ Fall 2024 (8 decks)

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