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Clinical Skills I > PAD > Flashcards

PAD Flashcards

1
Q

MC sites for PAD

A

Carotid bifurcation
Proximal left anterior descending coronary artery (LAD)
Proximal renal arteries
Abdominal aorta

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2
Q

PAD: Why is screening important?

A
  • Marker for cardiovascular morbidity & mortality
  • Risk of death from MI & stroke triples
  • sign of functional decline
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3
Q

PAD risk factors

A
  • Diabetes
  • Smoking
  • Obesity (BMI >30)
  • HTN
  • High Cholesterol
  • older age
  • Family hx of PAD, CAD
  • High levels of homocysteine (AA in blood with high meat diet)
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4
Q

PAD pathophysiology

A
  • Atherosclerotic ds: chronic inflammatory ds initiated by injury (smoking/HTN)
  • damage to vascular endothelial cells -> plaque formation -> narrow lumen -> obstruction
  • obstruction = decreased perfusion to meet metabolic demands -> ischemia + SYMPTOMS
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5
Q

PAD: collateral circulation

A

Collateral circulation: blood flow shifts to smaller arteries which parallel the disease artery
- anastomoses between branching networks of smaller arteries can increase in size over time to form collateral circulation that perfuses structures distal to the occlusion

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6
Q

PE/DVTs: Thromboembolic disorders, Superficial venous thrombosis

A

DVT in upper extremities = 10% of DVT cases
- IATROGENIC causes: catheters, pacemakers, ICDs

Superficial venous thrombosis: 1/3 of pts have DVT/PEs

Thromboembolic disorders:
- 1/3 of pts have PEs with 1/4 of the cases present with SUDDEN DEATH

never miss PE!!!!!

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7
Q

Arterial anatomy + plaque formation

A

Three concentric layers:
- intima (innermost - plaque formation begins here!!!)
- media
- adventitia (outermost)

Intima:
- plaque formation begins here where LDLs undergo modification -> local inflammatory response that attracts phagocytes and become FATTY streaks
- atheroma starts to form: FATTY LAYER

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8
Q

Intima function

A

Intima: remarkable metabolic properties
- Synthesizes regulators of thrombosis: helps with stopping bleeding
- Controls influence on blood flow: widens or narrows
- Regulates immune & inflammatory reactions

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9
Q

large vs medium vs small arteries and role in arterial flow

A

size vary according to their distance from the heart
- large = HIGHLY ELASTIC: aorta, common carotid, iliac
- medium sized = muscular: coronary and renal arteries
- small = ARTERIOLES = RESISTANCE TO BLOOD FLOW HERE -> principal determinant of systemic vascular resistance
- capillaries = rapid diffusion of O2 and CO2; ENDOTHELIAL cell lining with no media

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10
Q

what contributes to the propagation of blood flow and arterial pulsatile flow?

A

elastic recoil and smooth muscle contraction and relaxation in the media of LARGE- and MEDIUM-sized arteries

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11
Q

Palpating pulses in the arteries of the arm: brachial, radial, ulnar, hand vascular arches

A

Brachial artery: at the bend of the elbow
- MEDIAL to the biceps tendon in antecubital crease
- flex elbow slightly

Radial artery on the LATERAL flexor surface of wrist
- finger pads on flexor surface of wrist -> compare b/l pulse

Ulnar artery on the MEDIAL flexor surface
- overlying tissues may obscure pulsations in the ulnar artery

hand: vascular arches
-connect the radial and ulnar arteries
-protect circulation to the hand and fingers from arterial occlusion

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12
Q

Celiac trunk, superior mesenteric artery, inferior mesenteric artery

A

Celiac trunk: esophagus, stomach, proximal duodenum, liver, gallbladder, pancreas, spleen (foregut)

Superior mesenteric artery: SMALL intestine—jejunum, ileum, cecum; LARGE intestine—ascending and transverse colon, up to right splenic flexure (midgut)

Inferior mesenteric artery: LARGE intestine—descending and sigmoid colon, proximal RECTUM (hindgut)

acute mesenteric ischemia = life threatening

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13
Q

femoral, popliteal, posterior tibial, dorsalis pedis

A

Femoral: below inguinal ligament
- NAVEL: nerve, ARTERY, vein, empty, lymphatics
- palpate midway between the anterior superior iliac spine and the symphysis pubis

Popliteal:
- passes medially behind the femur
- palpable behind knee
- place fingertips midline + deeply press into popliteal fossa

Posterior tibial:
- behind and slightly below medial malleolus of ankle

Dorsalis pedis: dorsum of foot;
- palpate lateral to extensor tendon of big toe

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14
Q

Venous system characteristics

A
  • THIN WALLED
  • highly distensible -> can hold up to 2/3 of circulating blood
  • ONE WAY VALVES (unidirectional): promote venous return to the heart, prevent pooling, prevents backward flow
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15
Q

which veins connect saphenous/superficial vein system with deep system

A

PERFORATING VEINS

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16
Q

Deep veins vs superificial veins

A

Deep veins:
- carry 90% of venous return from lower extremities; well supported

Superficial veins:
- great saphenous : joins with femoral vein just below inguinal ligament
- small saphenous: joins the deep venous system in the popliteal fossa
- poor tissue support
- anastomotic veins connect the two saphenous veins

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17
Q

what serves as venous pump

A

-Contraction of calf muscles serves as venous pump during WALKING
-Propelling blood upward against gravity

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18
Q

Lymphatic system definition

A

Lymphatic system: drains lymph fluid from body tissues and returns it to VENOUS circulation
- start as lymphatic capillaries (little vacuums in spaces between cells)
- capillaries -> vessels which then pass through lymph NODES
-LNs: filtration points along vessels that remove pathogens, debris from the fluids + PRODUCE ANTIBODIES
- ROLE IN BODY’S IMMUNE SYSTEM

19
Q

Lymph node description

A
  • filtration points along vessels that remove pathogens, debris from the fluids + PRODUCE ANTIBODIES
  • round, oval, bean shaped structure
  • only superficial LNs palpable on PE
20
Q

Lymphatic system: major ducts + where they drain into

A

right lymphatic duct: draisn into the R internal jugular and subclavian veins

thoracic duct: drains into the L internal jugular and subclavian veins

21
Q

LNs: lower limb palpating

A

superficial group: horizontal and vertical group
- horizontal: just below inguinal
- vertical: near great saphenous
- note size, consistency, tenderness
- can palpate discrete nodes that are up to 1-2 cm in normal person

Horizontal:
- drains superficial lower abdomen and buttock, external genitalia (minus testes), anal canal, perianal area, vagina

Vertical:
- leg

22
Q

palpate epitrochear LNs

A
  • flex elbow 90 degrees while supporting forearm
  • feel in groove between biceps and triceps
  • 3cm above medial epicondyle

palpable LNs: signals generalized lymphadenopathy or infection:
- syphillis
- HIV

23
Q

Lymphatic drainage of the upper extremities:

A

Ulnar surface, hand, 3rd, 4th fingers -> epitrochlear LNs -> axillary LNs

24
Q

warning signs of PAD

A

-Fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, identify the location
- ED
- poorly healing or nonhealing wounds of the legs or feet
- Any pain present when at rest in the lower leg or foot and changes when standing or supine
- Abdominal pain after meals with associated FOOD FEAR and weight loss
- first-degree relatives with an AAA

25
Q

Common or Concerning Symptoms in PAD

A

-Pain and/or swelling of legs or arms

-Cramping in legs on exertion with relief with rest within 10 minutes (intermittent claudication, found in 10% of pts)*
- MC site for claudication = calf

-Cold, numbness, pallor or discoloration in the legs; hair loss

  • Abdominal, flank, or back pain

note: MOST PTS WITH PAD ARE ASYMPTOMATIC

26
Q

what is the associated artery for each PAD complaint

A
27
Q

Abdominal, Flank, or Back Pain

A
  • if sx are provoked with eating: most likely an arterial pathology where abdominal viscera have greater O2 demand
  • AAA: can compress bowel or ureters -> FLANK PAIN

DDX:
- FOOD FEAR + anorexia = chronic intestinal ischemia of the celiac or superior or inferior mesenteric arteries**
- mesenteric ischemia from arterial embolism
- arterial or venous thrombosis
- bowel volvulus or strangulation
- hypoperfusion

28
Q

Cold, Numbness, Pallor or Discoloration in the Legs/Hair Loss: where to check and what can it lead to

A
  • check for hair loss at anterior tibia: sign of decreased arterial perfusion
  • could lead to GANGRENE: “Dry” or brown-black ulcers
29
Q

In patients with central venous catheters… what questions/concern

A

concern for catheter associated thrombosis -> UPPER EXTREMITY DVT
- most pts are asymptomatic
- 10% of DVT cases: cardiac venous catheters, pacemakers, ICDs
- sx pt: presents with UNILATERAL SWELLING OF EXTREMITIES

ask about:
- arm discomfort
- pain
- unilateral swelling
- paresthesia + weakness

30
Q

Virchow’s triad

A

Risk factor for lower extremity DVT = virchows triad (+ AGE)
- hypercoagulability
- venous stasis
- endothelial/vessel wall injury

ask if there is pain or swelling

31
Q

Screening test for lower PAD

A

Use Ankle Brachial index to test!!!!***
- MOST PTS ARE ASYMPTOMATIC!!
- guidelines: need to screen pts with RISK FACTORS

RISK FACTORS:
- over 65 yrs
- 50+ yrs with Hx of DM or smoking
- leg sx with exertion
- non-healing wounds

Sensitivity: 15% to 20%
- This means that when the test result is normal: chance that the person might actually have PAD
- The test misses some cases

Specificity: 99%***
- This means that if the test result is abnormal, it’s almost certain that the person HAS PAD

32
Q

Specific vs Sensitive Test

A

Specific : SPIN
- positive test gives you high confidence rules in a disease
- ABI = 99% specific

Sensitive: SNOUT
- negative with confidence to rule out a disease

33
Q

Screening for Abdominal Aortic Aneurysm: definition and risk factors

A

AAA: diameter over 3 cm; over 5.5 = HIGH chance of rupture

risk factors:
- old age(65-75), male, smoking (over 100 cigarettes lifetime), family hx of AA
- less important: Hx of other vascular aneurysms, taller height, CAD, cerebrovascular disease, atherosclerosis, HTN, and hyperlipidemia

34
Q

Screening for Abdominal Aortic Aneurysm: what test and screening criteria

A

Screening test: ABDOMINAL US*
- reduces AAA-related mortality by 50%*
- guideline: one time abdominal US in men ages 65-75 who have smoked 100+ cigarettes (B)*
- can selectively offer screening men 65-75 who have never smoked (C)
- DONT SCREEN: women who have never smoked; iffy/insufficient evidence for women who have smoked
- US = noninvasive, inexpensive, and accurate

35
Q

Screening: Renal Artery Stenosis what signs for suspicion

A

-Early Onset Hypertension: under 30
- Severe Late-Onset Hypertension: Severe HTN starting at age 55+
- Resistant Hypertension: 3+ drugs
- malignant hypertension: signs of acute end-organ damage
- Worsening Renal Function: Decline in renal function after starting an ACEi/ARB
- Unexplained Small Kidney (CKD!!)
- Pulmonary Edema: Sudden unexplained… worsening renal function or CHF

36
Q

Screening: Renal Artery Stenosis what type of pts have RAS

A

pts with:
- End-stage renal disease
- CHF
- DM
- Hypertension
- Less commonly: Fibromuscular dysplasia (women over 40 yrs)

Associated Risks: Increases risk for cardiovascular events.

37
Q

Screening: Renal Artery Stenosis what test

A

Ultrasound
Magnetic Resonance Angiography (MRA)
Computed Tomography Angiography (CTA)

38
Q

grading pulse

A
39
Q

Check for pitting edema

A

Press firmly with THUMB for 2 s over:
- dorsum of foot
- behind medial malleolus
- shins

0 = NORMAL
1+: 2 mm
2+: 4mm (15s to rebound)
3+: 6mm (30s to rebound)
4+: 8 mm (>30s to rebound)

40
Q

pitting edema ddx

A

Lymphedema:
- no pigmentation

Venous stasis/chronic venous insufficiency:
- venous stasis = PAINFUL
- normal pulse
- BROWN pigmentation: hemosiderin deposits (leaked Hb into interstitial space)
- ulcerations

Venous dermatitis

41
Q

Chronic venous insufficiency

A
  • venous stasis = PAINFUL
  • sx: gradual progressive pitting edema; heavy tired legs at the end of the day; itching dull pain
  • normal pulse
  • BROWN pigmentation: hemosiderin deposits (leaked Hb into interstitial space)
  • chronic ulcerations with irregular border
  • MEDIAL MALLEOLUS ULCER
  • skin: shiny, atropic, color
42
Q

Chronic Insufficiency of Arteries and Veins

A
43
Q
A

know!

44
Q

ABI: how to obtain and what equation

A

before: rest supine in warm room for 10 minutes

test: use DOPPLER
- 2 readings of BP on the brachial pulse (L AND R)
- take average of L and R BP and use the higher avg as denominator

  • 2 readings of dorsalis pedis pulse and posterior tibial pulse (L and R)
  • take average BP for both sides and choose the highest average and thats the numerator

right ABI = (highest R average ankle pressure (DP vs PT)) / (highest average arm pressure (L vs R))
- over 0.9-1.4 = normal
- 0.6-.89 = mild PAD (under 0.9 = DIAGNOSTIC)
- 0.4-0.59 = moderate PAD
- under 0.4 = severe PAD

Clinical Skills I (11 decks)

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