C: Week 2 Flashcards
Arterial Wound
- Wound that results from a lack of blood flow which deprives the area of oxygen
- 5%-10% of all LE ulcerations are because of arterial insufficiency
Arterial vessels outer most layer to inner most layer
1.)Tunica Adventita= protective layer + supportive outer layer
2. Tunica Media=
3.) Tunica Intima= delicate layer in contact with the blood cells
Acute Embolism (Etiology of Arterial Insufficiency)
A clot stops blood flow to an area + damages arteriole wall when a clot gets stuck
Thromboangiitis Buerger’s Disease (Etiology of Arterial Insufficiency)
- Inflammation of the small vessels
- When inflamed they can include things like swelling which makes them close off
Atherosclerosis (Etiology of Arterial Insufficiency)
Thickening or hardening of arteries
- #1 reason for Arterial Insufficiency
Atherosclerosis (Etiology of Arterial Insufficiency)
-Systemic process by which the vessels narrow
- lipids + calcium deposits + scar tissue accumulate on the inner lining of the arteries and narrow the lumen- stenosis
-High LDL’s lead to a deposition of plaques into the arteries
Intermittent Claudication
- It is activity specific discomfort due to local ischemia
- Pain stops within 1-5 minutes of ceasing activity
- Pain location is usually distal to the site of occlusion
- Demand of O2 exceeds what they can supply
If there is intermittent claudication in the Iliofemoral artery obstruction where would the person feel the pain?
Buttock, thigh, calf pain
If a person had a Infrapopliteal artery obstruction where would they feel the pain?
foot pain
Ischemic Rest Pain
- More significant arterial disease
- Burning pain exacerbated with elevation and relieved by dependency
- Increasing Tissue O2 demand can fatally upset the balance between O2 supply and tissue demand causing ulceration
The progression of Arterial Insufficiency
Arterial Insufficiency–> Intermittent Claudication–> Ischemic rest pain –> Ulcer
Gangrene
- when oxygen supply does not equal demand you have cell death
- dead tissue typically dry, dark, cold, and contracted
-Dry= stable its ok (good), circulation, proximal, keep it dry - Wet not good
Diabetes (Etiology of Arterial Insufficiency)
- Arteries tend to accumulate calcium making them harder + narrowing the openings of the vessels -stenosis
-prolonged hyperglycemia impairs angiogenesis, fibroblast proliferation, collagen synthesis and overall strength of scar tissue and impairs all 3 phases of healing
What is the A1c level of a normal person and a diabetic
Normal= 5.7
Diabetic= anything less than 7
Difference between neuropathic wound and an arterial wound
Neuropathic wound happens over points of pressure like a bed sore
Arterial wound happens from ischemic tissue dying and forming an ulcer
Characteristics of an Arterial Wound
- Pain- severe unless masked by neuropathy- pain increases with elevation
- Position- Primarily LE, Distal toes, Dorsal Foot, areas of trauma
- Presentation
–> Regular appearance
–> may conform to precipitating trauma
–> pale granulation tissue if present
–> Black eschar
–> gangrene
–> little to no drainage - Periwound & Extrinsic Tissue
–> thin, shiny, anhydrous skin
–> loss of hair growth
–> thickened yellow nails
–> pale, dusky, or cyanotic skin
–> dependent rubor
–> edema unusual, may indicate VI or CHF - Pulses- decreased or absent pedal pulse
- Temperature- cool/decreased
Wound Presentation Arterial Insufficent Wounds
- 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 or yellow if bandaged for wound moisture
- Minimal to no wound drainage even with infection
Physical Therapist Tests for Arterial Insufficiency
- Pulses
- Doppler Ultrasound
- ABI
- Rubor of Dependency
- Capillary Refill
- Venous Filling Time
Doppler Ultrasound
- Indications: decreased or absent pulses
- Helpful in assessing arterial Patency
- method of assessment when pulses cannot be palpated easily
ABI Indications
- Decreased/absent pulses
- Signs/symptoms of AI
- History of PVD
ABI 1.1-1.3 =
- vessel Calcification
- ABI is not a valid measure of tissue perfusion
- Referral to vascular
ABI 0.9-1.1=
- Normal
- Okay to debride
ABI 0.7-0.9=
- Mild to moderate Arterial Insufficiency
- Conservative interventions normally provide satisfactory wound healing
- 0.8-0.5: clinical judgment required for debridement
ABI 0.5-0.7=
- Moderate arterial insufficiency, intermittent claudication
- May perform trial of conservative care, physician may consider revascularization
- 0.8-0.5: clinical judgment required for debridement
ABI <0.5 =
- Severe arterial insufficiency, rest pain
- Wound is unlikely to heal without revascularization, limb threatening arterial insufficiency
- <0.5 referral to vascular surgeon
ABI <0.3 =
- Rest pain and gangrene
- Revascularization or amputation
Arterial Insufficiency Medical and surgical interventions
- Prescription drugs
- Revascularization
- Percutaneous Balloon Angioplasty= procedure in which balloon tip catheter is expanded at a site of stenosis: compressing any of the plaque formation that is obstructing the blood flow against the wall and then opening the vessel
- Amputation: earlier is better than later in terms of healing potential
Physical Therapy Management for Arterial Insufficiency
- Limb protection from trauma, chemicals, excessive heat/cold, protect open wounds, live healthy
- Therapeutic exercises: strengthening, aerobic exercise, stretching, positioning, gait training and mobility
Venous Insufficiency Definition
- Condition where the veins particularly in the lower extremities have difficulties sending blood back to the heart
Type of Veins: Deep
- Popliteal
- Femoral
- Tibial
Carry 80-90% of blood back to the heart
Type of Veins: Superficial
- Greater/Lesser Saphenous veins
- Drain skin and subcutaneous tissues
- ## Assist with temperature regulation
Type of Veins: Perforating Veins
- Connect deep and superficial veins
- 60-100 perforating veins in each leg
True false: Venous insufficiency is a low pressure system
True
Calf muscle Pump
Main way we get blood back to the heart+ calf muscle contracts the veins get compressed blood forced up leg
Respiratory Pump
Every time we inhale/exhale
- Inhale = decrease in thoracic pressure + increase in abdominal pressure which provides a pressure gradient to drive blood back to the heart
Valves
present to prevent retrograde blood flow (backwash)+ preventing increase venous back pressure (venous hypertension)
What are the common causes of Venous hypertension?
- Vain dysfunction
- incompetent superficial and perforating veins
- Valve damage
- Calf muscle pump failure
White Blood Cell Trapping Theory
- congestion + distention is caused by venous hypertension
- distention encourages WBC’s to come to the area which further increases congestion
- WBC’s adhere to the vessel walls and become trapped
- Trapped WBCs trigger inflammatory response which encourages more cells to an already congested area
-WBCs releasing substances that further damage the epithelial lining of the veins - Ulcer will ultimately develop from local hypoxia caused by the trapped WBCs
Fibrin Cuff Theory
The distention caused by venous hypertension will make the veins leaky
- Leaky veins allow proteins and fluids to escape into interstitial tissue causing swelling and edema
- Fibrinogen is leaked once in the interstitial it will convert fibrin
- Which then adheres to the capillary walls forming a cuff
- Cuff then prevents O2 + nutrients exchange to the skin so the skin dies and ulcer develops
Venous Insufficiency Ulcer: Pain
- mild to moderate unless masked by neuropathy
- decreases with elevation /compression
Venous Insufficiency Ulcer: Position
- Medial Malleolus
- Medial Leg
- Areas of Trauma
Venous Insufficiency Ulcer: Presentation
- irregular shape
- Fibrous, glossy coating
- Red, ruddy wound bed
- Copious drainage
Venous Insufficiency Ulcer: Peri wound and Extrinsic Tissue
- Edema
- Dermatitis and cellulitis common
Hemosiderin staining
Lipodermatosclerosis
Venous Insufficiency Ulcer: Pulses
- Normal or decreased due to edema or concomitant arterial insufficiency
Venous Insufficiency Ulcer: temperature
- Normal to mild warmth
