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Integ > Lecture 4a - Vascular Ulcers > Flashcards

Lecture 4a - Vascular Ulcers Flashcards

1
Q

What % of all LE ulcers are arterial ulcers?

A

5-10%

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2
Q

What does an arterial ulcer look like?

A
  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
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3
Q

Where are arterial ulcers normally found?

A

distal LE
commonly on toes, lateral malleolus, or anterior leg

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4
Q

Is there bleeding in arterial ulcers?

A

minimal bleeding/drainage

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5
Q

Are arterial ulcers painful?

A

Usually painful (cramping, aching, or fatigue) but can be masked by neuropathy

  • pain increased by activity and elevation of wound are
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6
Q

what type of ulcer is this?

A

Arterial Ulcer

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7
Q

Describe the arterial ulcer periwound.

A
  • lack of hair
  • skin is shiny, thin, dry
  • increased fungal growth
  • nails are yellow/thickened
  • limb is pale/cyanotic or shows dependent rubor
  • cold to touch
  • usually no edema
  • lack palpable pulses
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8
Q

Risk factors for arterial ulcers

A
  • Arterial insufficiency
  • Hyperlipidemia/elevated cholesterol
  • Smoking
  • DM
  • HTN
  • Trauma
  • Advanced Age
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9
Q

What are some causes for Arterial Insufficiency (AI)?

A
  • Trauma
  • Acute embolism
  • Thromboangiitis
  • Buerger’s disease
  • Microvascular disease
  • Arteriosclerosis/atherosclerosis
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10
Q

What is the primary cause of AI?

A

Arteriosclerosis: thickening/hardening of arterial walls

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11
Q

What’s the most common form of arteriosclerosis?

A

Systemic, degenerative process in which arterial lumen is gradually/progressively approached upon

  • circulating cholesterol attaches plaque to vessel walls
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12
Q

How does smoking lead to an increased risk for arterial ulcers?

A
  • Nicotine causes vasoconstriction
  • Decrease available O2
  • Increase clot formation rate & blood viscosity
  • Nicotine enhances cholesterol deposition in vessels
  • O2 delivery/demand mismatch
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13
Q

What is the #1 modifiable risk factor for PVD?

A

Smoking

80% of patients with PAD are current or former smokers

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14
Q

Why is Diabetes a risk for arterial ulcers?

A
  • increased calcification
  • hyperglycemia impairs all phases of healing
  • increased neuropathy prevalence that can mask pain
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15
Q

Which HTN is worse for arterial ulcers?

A

Systolic HTN is worse than diastolic HTN

  • increased force initiates / perpetuates endothelial cell injury
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16
Q

Although ulcers can occur spontaneously, most are caused by _____

A

trauma

including chemical & thermal traumas

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17
Q

Why is age a risk factor for arterial ulcers?

A

Difficulty adapting to metabolic demands; plaques build up over time

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18
Q

What does ischemic rest pain look like?

A

More significant arterial disease, burning pain occurs at night or with elevation and RELIEVED with dependency

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19
Q

If you hear “cramping, burning, fatigue,” you think _____ ulcer

A

Arterial Ulcer

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20
Q

If you hear that the ulcer is distal to the site of occlusion, repeatable or predictable, we’re thinking ______ ulcer

A

Arterial Ulcer

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21
Q

Some ways to test for an arterial ulcer include?

A
  • Pulses
  • Doppler Ultrasound
  • Capillary refill
  • Rubor
  • Venous filling time
  • ABI
  • TBI
  • Transcutaneous O2 monitoring
  • CTA
  • MRA
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22
Q

What is a doppler ultrasound?

A

Handheld probe that makes an audible signal when placed over moving fluid

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23
Q

Which pulses should you check for with arterial ulcers?

A
  • femoral
  • popliteal
  • dorsalis pedis
  • posterior tibial
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24
Q

Which testing is more sensitive to pulses: Palpation or Doppler Ultrasound?

A

Doppler Ultrasound

Slide says: The absence of palable pulses should be followed up with more sensitive testing such as Doppler Ultrasound.

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25
Q

When testing capillary refill time, how long should you push against the distal tip of the digit for? What is normal refill?

A

Push against digit for 3 seconds to bland

Normal capillary refill is 3 seconds; AI is >3 seconds

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26
Q

When testing rubor of dependency, patient should lie ______, elevate LE to be tested at ______ degrees for _____ minute(s).

A

When testing rubor of dependency, patient should lie supine, elevate LE to be tested at 60 degrees for one minute(s).

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27
Q

What is normal return time of arterial blood flow (rubor dependency test)?

A

15-20 seconds; AI takes longer

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28
Q

What is normal venous filling time?

A

5-15 seconds

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29
Q

What venous filling time indicates severe AI?

A

20 seconds

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30
Q

What does segmental pressure measurement help with?

A

Localizing areas of decreased arterial blood flow by holding doppler US probe over dorsalis pedis or post-tib artery & measure SBP with cuff above malleoli, below knee, or around thigh

Best with ID distal arterial occlusion or stenosis

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31
Q

What pressure drop in segmental pressure measurement testing is indicative of significant arterial occlusion?

A

drop of >20 mm Hg in adjacent segments

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32
Q

How do you calculate ABI?

A

Divide systolic pressure of the LE by systolic pressure of the UE

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33
Q

What do lower ABI values correlate with?

A

Increased severity of atherosclerosis and CAD and PAD

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34
Q

What ABI systolic pressure has poor healing potential?

A

Systolic pressure of <60-80 mm Hg

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35
Q

If your patient _____, the ABI values will be lower on the day of the test.

A

Smoked!

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36
Q

Normal ABI value

A

0.9-1.1

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37
Q

ABI Value Interpretation

1.1-1.3

0.7-0.9
0.5-0.7
<0.5
<0.3

A

1.1-1.3 Vessel Calcification

0.7-0.9 Mild to moderate AI
0.5-0.7 Moderate AI, intermittent claudication
<0.5 Severe AI, rest pain
<0.3 Rest pain and gangrene

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38
Q

What TBI pressure is indicative of good healing potential?

A

> 30 mm Hg

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39
Q

What is Transcutaneous Oxygen Monitoring used for?

A

To evaluate slow healing wounds and evaluate for severity of PVD

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40
Q

How do you perform Transcutaneous O2 Monitoring?

A

Place electrodes on periwound to measure O2 tension

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41
Q

What do these Transcutaneous O2 Monitoring values mean?

> 50 mm Hg
35 mm Hg
< 30 mm Hg

A

> 50 mm Hg Normal
35 mm Hg wound should heal
< 30 mm Hg needs surgical intervention

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42
Q

What is Plethysmography?

A

Pulse Volume Recordings

  • place multiple cuffs & pulsatile nature of blood flow causes changes in pressure within the cuff –> picked up by transducer and recorded as waveforms
43
Q

What is Plethysmography useful for?

A

Testing in noncompressible pedal arteries and to monitor limbs after revascularization surgery

43
Q

What does Duplex scanning provide info about?

A

Blood flow, velocity and turbulence in arteries and veins

44
Q

How do you perform Arteriography?

A

Dye injected into artery to better visualize blood flow

More invasive, so only done if surgery is being considered

45
Q

What is CTA/MRA used for?

CTA = computed tomography angiogram
MRA = magnetic resonance angiogram

A

3D visualization of blood vessels to detect abnormalities or obstructions

46
Q

Some ways to treat arterial ulcers/AI include?

A

local wound care
*ensure proper footwear
* gait/mobility training
* positioning
* exercise
* therapeutic heat
* meds
* surgical debridement
* open arterial surgeries
* atherectomy
* amputation

47
Q

What 4 things do you need to do in local wound care of arterial ulcers/AI?

A
  1. Protect the periwound
  2. Ensure moist wound bed & debride necrotic tissue
  3. Don’t compromise circulation (no compression)
  4. Educate pt/caregivers (intervention strategies, risk factors, foot care)
48
Q

What type of footwear might a pt w/ arterial ulcer/AI use?

A
  • Temporary footwear when they have bandages or waiting for appropriate footwear
  • Permanent footwear extra depth toe box, adequate length and space, accomodate deformities
49
Q

Gait and mobility training considerations for pts w/ arterial ulcers/AI

A
  • off-loading the wound (use of AD)
  • LE weakness
    titrated mobility exercises
50
Q

What positions should you avoid with arterial ulcers/AI?

A

extreme hip and knee flexion

51
Q

What type of exercise do you recommend for pts with arterial ulcers/AI?

A
  • Graded exercise program can stimulate collateral vessel formation over time
  • Resistive exercise
  • Flexibility exercises
52
Q

How does heat help arterial ulcers/AI?

A
  • Heat causes vasodilation and increases tissue SaO2 by decreasing HgB affinity for O2

Heat is gentle as tissue is fragile and cannot dissipate heat effectively

53
Q

How can pharmacology help arterial ulcers/AI?

A
  • Pain meds helps decrease pain, reduce anxiety
  • Pentoxifylline decrease blood viscosity, decrease platelet aggregation, increase RBC flexibility & vasodilation
  • Low dose aspirin decrease blood viscosity
54
Q

How does a sympathetic block help with arterial ulcers/AI?

A

Eliminate CNS control over vasoconstriction & improve circulation and healing

Done if revascularization cannot be done

55
Q

Surgical debridement of arterial ulcers can be done at the same time as ________ _________

A

revascularization surgery

56
Q

Do you need to debride arterial ulcers in an OR with sterile techniques?

A

Yes to decrease the chance of infection

57
Q

What are some endovascular surgeries for arterial ulcers/AI?

A
  • Balloon angioplasty
  • Stent angioplasty
  • Drug coated balloon angioplasty
  • Drug eluting stent angioplasty
  • Atherectomy
58
Q

_____ cannot be safely done below the knee (it causes clots d/t decreased pressure in vessel) so it has to be balloon angioplasty below the knee

A

Stent

59
Q

What is a “kissing stent”?

A

At iliac, if only one side is done, it pushes all the plaque into the other side so they must do both sides

60
Q

What are the 2 open heart surgeries for arterial ulcers?

A
  1. Bypass
  2. Endarterectomy
61
Q

What is the treatment of choice for gangrene?

A

Amputation
- may be necessary if the pt is not able to heal and circulation is not improved

NOT A FAILURE

62
Q

3 Precautions with AI

A
  1. Compression
  2. Contraindication: sharp debridement to dry stable heel ulcer or gangrene
  3. Precaution w/ sharp debridement w/ ABI <0.5 and contraindicated w/ ABI <0.3
63
Q

What is an indicator of good prognosis for arterial ulcers?

ABI > ___

A

0.5

64
Q

What is an indicator of good prognosis for arterial ulcers?

TBI > __ mm Hg

A

50

65
Q

What is an indicator of good prognosis for arterial ulcers?

Transcutaneous O2 levels > ___

A

30

66
Q

What is the most common type of leg ulcer?

A

Venous ulcer

67
Q

Venous wound is usually (superficial/deep) with (regular/irregular) shape and moderate to max drainage

A

Venous wound is usually superficial with irregular shape and moderate to max drainage

68
Q

Describe the venous ulcer periwound.

A
  • Skin is dry/scaly
  • often has cellulitis/dermatitis
  • often find varicosities/previous ulcerations
  • Edema (pitting)
  • Hemosiderin deposition
  • Lipodermatosclerosis
  • Pulses are present
69
Q

review your classification of venous ulcers

A

idk if we need to know them

C0-C6

70
Q

What are the 2 pumps that help the venous system?

A
  1. Respiratory pump: pressure change with breathing
  2. Muscle pump: muscle contracts and pushes blood proximal
71
Q

Venous ulcer risk factors

A

anything that causes venous hypertension

  • Vein dysfunction
  • Calf muscle pump failure
  • Trauma
  • Previous venous insufficiency ulcer
  • Advanced age
  • DM
72
Q

What are the most common causes of venous HTN?

A
  1. Vein dysfunction
  2. Muscle pump failure
  3. both
  4. obstruction to venous outflow
73
Q

Is the venous system high or low pressure?

A

Low pressure

  • relies on calf muscle to move blood from distal LEs up against gravity
74
Q

If you had a previous venous ulcer, the recurrence rate is as high as ___%

A

81%

75
Q

_______fold increase in venous sufficiency over age 65

A

Sevenfold increase

76
Q

Venous Ulcer Testing Methods (6)

A
  1. Venogram
  2. Ultrasonography
  3. Homan’s sign
  4. Well Clinical Prediction guideline
  5. ABI
  6. Trendelenburg Test
77
Q

What is the gold standard to identify DVT?

A

venogram

  • expensive
  • invasive with dye
  • may cause DVT 5% of the time
78
Q

Using Wells CPG, what score should be considered to have high probability of DVT and be referred for testing?

A

Score of 3 or greater

79
Q

____% of all LE are both arterial and venous ulcers

A

15-20

difficult since you can treat venous with compression but can’t compress arterial ulcers

80
Q

If you have an ulcer that is both arterial and venous, ABI of < ____ should not be managed with compression.

A

ABI < 0.7 = NO COMPRESSION

81
Q

Trendelenburg test tests for _____ ______.

A

Vein incompetence

82
Q

In the Trendelenburg test, you record time when superficial venous distention occurs. < ______ seconds = deep or perforator vein incompetence

A

<20 seconds

Venous distention occurring shortly after tourniquet is released = superficial vein incompetence

83
Q

What is normal venous filling time?

A

5-15 seconds

84
Q

What is immediate venous filling time indicative of?

A

Venous insufficiency

85
Q

Venous Ulcer Tx includes:

A
  • Local wound care
  • Compression therapy*
  • Vasopneumatic compression devices
  • Exercise
  • Gait & Mobility Training
  • Pharmacology
  • Surgical debridement
  • Skin grafts
  • Vein surgery
86
Q

4 key factors of local wound care for venous ulcers

A
  1. Protect surrounding skin
  2. absorb drainage
  3. enhance venous return
  4. educate pt/ caregivers
87
Q

Wound care for venous ulcers

A
  • Compression
  • biological dressings
  • Negative pressure wound therapy
88
Q

For mild-mod venous insufficiency _____ mm Hg at ankle decreasing to 10 mm Hg at infrapatellar notch

For severe venous insufficiency _____ mm Hg at ankle decreasing to 10 mm Hg at infrapatellar notch

A

Mild-mod 30-40 mm Hg

Severe 40-50 mm Hg

89
Q

Contraindications for compression therapy

A
  1. ABI <0.7
  2. Acute infection
  3. Pulmonary edema
  4. uncontrolled or severe CHF
  5. active DVT
  6. severe claustrophobia
90
Q

6 types of compression bandages

A
  1. Paste bandage (Unna boot)
  2. Short-stretch (elastic or inelastic)
  3. Multi-layer compression bandage system (4 layers)
  4. Circaid (velcro)
  5. Tubular bandage
  6. Compression garments
91
Q

Will someone with venous insufficiency have difficulty walking?

A

Yes, bc of effects of gravity

91
Q

Average healing time for venous ulcers (full thickness)

A

8 weeks

small: 5-7 weeks
larger: 10-16 weeks

92
Q

30-60% treated with compression will heal within ____ months

A

3 months

93
Q

What are predictors of poor prognosis of venous ulcer healing?

A
  • deep vein involvement
  • concomitant arterial insufficiency
  • high body mass
  • increased age

recurrence is common

94
Q

Venous or arterial?

A

Venous

95
Q

Venous or arterial

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
95
Q

Venous or arterial

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
95
Q

Venous or arterial

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
95
Q

Venous or arterial

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
95
Q

Venous or arterial?

A

Venous

95
Q

Venous or arterial?

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area
95
Q

Venous or arterial

A

Arterial

  • round
  • regular shaped
  • punched-out appearance
  • pale wound bed
  • may have necrotic tissue
  • may present as dry gangrene-dry, dark, cold, and contracted area

Integ (14 decks)

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