Peripheral Circulation

Question 1

What is the pulse ?

Answer 1

It’s the palpable systolic pressure when the wave of the heart beat pass, causing the arterial wall to expand and return.

Question 2

Where do you palpate the pulse ?

Answer 2

Radial artery, carotid artery, femoral artery.

Question 3

What is a normal pulse ?

Answer 3

60-100 bpm
Lower => brachycardia
Higher => tachycardia

Question 4

What is a respiratory arrhythmia ?

Answer 4

When the heart speed up slightly during inspiration and slows down on expiration.

Question 5

How do you measure blood presssure ?

Answer 5

Measured in the brachial artery.
Increase the pressure until no pulse felt anymore because no flow.
Because there is no flow you will hear nothing with a stethoscope on the inner elbow.
Decrease slowly the pressure. When the vessel start opening, the systolic blood pressure is heard.
When the vessel are fully opened, we dont hear anything, this is the diastolic blood pressure.

Question 6

What is coarctation ?

Answer 6

Birth defect where part of the aorta is narrower than normal.

Question 7

What is the peripheral circulation ?

Answer 7

The network of arteries and venous system particularly those supplying the limbs (are and legs)

Question 8

What do you inspect ?

Answer 8

Swollen jugular vein and temporal artery ?
Vascularity around the shoulder ? Color, circumference of the arms and hands ? Abnormalities of finger and nails ?
Skin color, muscle atrophy, oedema, swelling, ulcers, wounds ?

Question 9

Where do you auscultate ?

Answer 9

Carotid artery, abdominal aorta, iliac artery, femoral artery.

Question 10

Why do you auscultate ?

Answer 10

To hear the pulse and detect bruits indicating stenosis or arteriovenous fistula => irregular connection between artery and vein.

Question 11

What does a white / pale color of the skin means ?

Answer 11

It is caused by vasoconstriction => capillaries are constricted and contains less blood
Caused by : cold, reduced arterial perfusion (acute peripheral artery occlusion)

Question 12

What does a red color of the skin means ?

Answer 12

Caused by vasodilatation => capillaries are open and contains more blood.
Caused by : heat, inflammation (trauma, infection, allergy), reduced venous outflow (deep venous thrombosis)

Question 13

What does a purple / bluish coloration of the skin means ?

Answer 13

Increased amount of deoxigenated blood = cyanosis.

Question 14

What does a black coloration of the skin means ?

Answer 14

Necrotic tissue that hasn’t received sufficient oxygen and nutrient for too long. Also called gangrene.

Question 15

What is atrophy ?

Answer 15

A process appearing after a chronic lack of oxygen caused a deterioration of the tissue. Caused by a chronic arterial deficiency.
Characterised by a dry thinner skin, reduced hair growth, thiner and softer subcutaneous tissue, reduced muscle mass, thickened yellowish deformed nails.

Question 16

What happen in a chronic venous insufficiency ?

Answer 16

Chronically poor reflow of blood from the tissues blood will accumulate or congest the tissues.
Characterised by skin coloration change, dermatosclerosis (hardening of the skin), eczema, increase venous marking, varicose vein, oedema, liposclerosis (hardening of the tissue), decreased muscle mass.

Question 17

What does a brown pigmentation means ?

Answer 17

Caused by the deposition of haemosiderin. Product of erythrocytes ending up outside the circulation due to increased pressure.

Question 18

What is atrophie Blanche ?

Answer 18

A white discoloration of the skin with scarring.

Question 19

What is telangiectasia ?

Answer 19

Dilated, small capillaries in the skin : red, purple or blue.

Question 20

What is an ankle flare ?

Answer 20

Star shaped distension of small venues below the malleolus.

Question 21

What is an ulcer ?

Answer 21

A defect of the entire skin (epidermis and dermis), usually crated shaped. It is difficult to heal and often leave scars. It can be either of arterial or venous form.

Question 22

What are the characteristic of an arterial ulcer ?

Answer 22

Present in place with pressure and poor perfusion (toes or feet). Relatively deep, dry aspect at the base and coloured (white/brown/black). It is very painful.

Question 23

What are the characteristic of an venous ulcer ?

Answer 23

Round shape, generally above the malleoli (medial), relatively superficial. Wet aspect at the base (discharge present), coloured (pink/red/yellow). It is mildly painful.

Question 24

What is pitting oedema ?

Answer 24

The pressure applied to it result in a visible indentation ‘pit’ in the tissue that slowly disappear.
Caused by accumulated extracellular fluid due to disturbed balance between supply and outflow : increase venous pressure or vascular permeability.

Question 25

What is a non-pitting oedema ?

Answer 25

Pressure applied does not result in a visible indentation, the tissue is firm, skin thickened and though.
Caused by accumulated lymph due to disturbed lymph outflow : inflammation, tumour or fibrosis.

Question 26

What is the central venous pressure ?

Answer 26

Also called CVP. It describes the pressure of the blood in the thoracic vena cava, reflect the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system.

Question 27

What sound do you hear when taking blood pressure ?

Answer 27

The Korotkoff sounds caused by the turbulence against the vascular wall in the artificially contracted artery. You hear Korotkoff 1 and 5.
Sometimes the 5th cannot be detected in : children, pregnant women, anaemia patient.

Question 28

What factor influence the blood pressure ?

Answer 28

Day-night rythm : at its lowest in the middle of the night (deep sleep)
Recent activities : physical exertion, coffee, tobacco, recreational drugs
Environmental factors : temperature, loud noise, bright light
Internal stimuli : pain, stress, emotions

Question 29

Why do you keep palpating the radial artery while taking blood pressure ?

Answer 29

People with hypertension : silence in the 2nd Korotkoff phase (after Korotkoff 1) before they resume in Korotkoff 3. Called silent gap / auscultatory gap.
Palpating the radial artery allow you to feel the systolic blood pressure.

Question 30

What is the ankle brachial index ?

Answer 30

Quotiënt of the highest systolic blood pressure measurable at the ankle compared with the highest pressure measure in one of the 2 arms.

It measures the arterial circulation of the leg.

Question 31

Technique of Arterial Doppler ultrasound ?

Answer 31

Measure systolic pressure in the arms with either automatic sphygmomanometer or Doppler.
Measure systolic blood pressure in the leg with Doppler on dorsalis pedis and posterior tibial arteries.
- pump the cuff cranial to the malleolus
- note the pressure point where the Doppler signal is heard again using the probe

Question 32

What are possible errors of an Arterial Doppler ?

Answer 32

It may not be possible to compress the lower artery if it is severely calcified.
- Give incorrect (too high) measurement

Unilateral/bilateral obstruction of subclavian artery
- arm pressure may be too low

Mild arterial obstruction
- normal bp in the ankle of a supine patient

If the probe presses too hard there’s a chance it can compress the vessels
- no blood flow

Question 33

Ankle brachial index : result

Answer 33

Lower than 0.9 = peripheral arterial disease

Absolute ankle pressure :
- below 75 mm = severely restricted circulation
- below 50 mm = indication for angiography in preparation for treatment

Question 34

Risk factors for venous ulcers ?

Answer 34

Varicose veins, DVT, chronic venous insufficiency, poor calf muscle function, arteriovenous fistulae, obesity, history of leg fracture.

Deficiency in proteins and antithrombin 3 (lead to DVT)
Family history of varicose vein
Minor trauma

Question 35

How do you manage the treatment of a venous ulcer ?

Answer 35

Compression :
- Graded compression : greatest at the ankle
- compression bandage

Surgery : to correct superficial venous disease

Broad spectrum antibiotics for 2 weeks if infected
- avoid topical antibiotics

Question 36

Aftercare of a venous ulcer ?

Answer 36

Wear compression stocking, leg elevation
Skin care, calf exercise, diet

Question 37

Risk factors for arterial ulcers ?

Answer 37

Most common in men >45y and women >55y with history of atherosclerotic disease

Smoking, obesity, diabetes, decreased activity
Hyperlipidemia, hypertension
History of vascular problems : MI, angina, stroke, claudication

Question 38

Management of arterial ulcers ?

Answer 38

Increasing the blood flow via reconstructive surgery or angioplasty
- Indicated if : non healing ulceration, gangrene, rest pain, progression of disabling claudication

Antibiotics if infection

Self care : stop smoking, control diabetes/hypertension/hyperlipidemia, sleeping in raised bed, walking

Question 39

Classification of the peripheral arterial disease : Fontaine system ?

Answer 39

1 : arterial obstruction without typical symptoms
2 : claudication symptoms before/after 100m
3 : ischaemic rupture at rest
4 : ulcers, risk of necrosis or gangrene

Question 40

What is Charcot foot ?

Answer 40

= neuro-osteoarthopathic foot : sterile inflammation of diabetic foot

Can cause middle foot to collapse : shape of rocking chair. Abscess suggested with shiny red swelling.