Peripheral Vascular Flashcards
What is a good way to remember what to do in each section of the peripheral vascular exam
TCPS (Remember ‘Tightly Constricting Pipes Squeeze’)
What should you inspect for in the peripheral vascular exam
Trophic changes
Colour (cyanosis, pallor, redness)
Pressure points (between toes, under heels - ULCERS)
Scars (check groin and inside of legs)
TCPS
Missing limbs!
What do trophic changes include in the inspection of the lower limb when assessing peripheral vasculature
- Muscle atrophy
- Hair loss
- Shiny skin
- Thickened toenails
What do you feel for in the peripheral vascular exam
Temperature
Capillary Refill Time
Pulses
Sensation
What are the pulses in the lower limbs?
Remember to auscultate over femoral and popliteal for bruits
1. Aorta
2. Femoral – at midinguinal point (1/2 way between ASIS + PS)
3. Popliteal – at popliteal fossa
4. Posterior tibial – 2cm below and behind medial malloeous
5. Dorsalis pedis – lateral to extensor hallucis longus, over 2nd/3rd cuneiform bones
How do you assess the lower limb sensation in the peripheral vascular exam
- Assess crudely by light touch
- Distal → proximal
What are the special tests in the peripheral vascular exam
Buerger’s angle
Buerger’s test
How do you test for Buerger’s angle
Give interpretation
. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
- Observe the colour of the limbs:
The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle.
In a healthy individual, the entire leg should remain pink, even at an angle of 90º.
A Buerger’s angle of less than 20º indicates severe limb ischaemia.
What is Buerger’s test
Sit the patient up and ask them to hang their legs down over the side of the bed:
Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).
What further tests should you do after the peripheral vascular exam
- Cardiovascular examination
- LL neuro examination
- Doppler pulses (if not found)
- ABPI measurement
What pulses do you assess in the upper limbs in the peripheral vascular exam
What should you do after this? And after this?
Radial - assess rate and rhythm
Radio-radial delay
Brachial - assess volume and character
Offer blood pressure then Carotid pulse (auscultate and palpate)
Then move to the abodmen
What do you do on the abdomen in the peripheral vascular exam
Inspect (TCPS)
Palpate - aorta
Auscultate - aorta and renal arteries
What is a difference in BP between arms suggestive of
A more than 20 mmHg difference in BP between arms is abnormal and is associated with aortic dissection.
What is a wide pulse pressure suggestive of
Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection.
What is a radio-radial delay suggestive of
Causes of radio-radial delay include:
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
How should you inspect a patient’s legs for venous changes
What should you look for (7)
Patient standing: look at front, sides, and back
Venous eczema
Haemosiderin deposition
Atrophe blanche
Lipodermatosclerosis
Ulcers
Scars (check groin)
Varicose veins/ saphena varix
What should you feel for when inspecting the legs for venous changes
palpate for pitting oedema, pulses, saphena varix
Feel for temperature (if hot may suggest thrombophlebitis)
Palpate along length - If tender and hard may suggest thrombophlebitis
What is saphena varix
How do you assess for it
a dilated saccular varicose swelling, arises from the proximal end of the long saphenous vein
2-4cm inferior-lateral to PT
* Bluish tint
* Soft to palpate
* Disappears on lying down
Ask patient to cough with hand over SFJ
What special tests can you do to assess the lower limb venous system
Tap test (Place one finger with a small amount of pressure onto the SFJ and Tap the varicose vein you are assessing)
Trendelenburg test
Tourniquet test
What is the Trendelenburg test (venous)
Give interpretation
What is the tourniquet test?
- Position the patient lying flat on the examination couch
- Lift the patient’s leg up and empty the superficial veins by “milking” the leg towards the groin
- Place finger over SFJ
- Ask the patient to stand and observe for filling of the veins
Interpretation
At this point, if the veins have not filled and remain collapsed, it indicates the incompetent venous valve(s) was at the level of the SFJ. If the veins have filled up again, it indicates the incompetent valve(s) are inferior to the SFJ (i.e. perforator veins – veins that drain venous blood from superficial to deep veins within the muscle)
- As for above but with tourniquet not fingers
- If negative, place tourniquet 3cm lower than the previous position, ask the patient to stand and observe venous filling
- Repeat until site of defect found
What are differentials for an acutely painful limb
If lower limb pain, what needs to be excluded?
- Acute limb ischaemia
- DVT
- Cellulitis
- Trauma
- Neurological (Central - MS; Spinal – disc herniation, CE; Peripheral – GBS, trauma)
Cauda equina syndrome
Ask: Back pain? incontinence of bladder/bowel? perianal sensation?
What should be your top 4 differentials for a leg ulcer?
- Venous ulcer (70%)
- Arterial ulcer (10%)
- Neuropathic ulcer
- Mixed venous-arterial ulcer
How does pain differ between venous, arterial, and neuropathic ulcers?
V- moderate
A - severe
N - painless
How do associated symptoms differ between venous, arterial, and neuropathic ulcers? (4, 4, 2)
V:
* Varicose veins
* Venous eczema
* Heavy legs
* Swelling
A:
* Claudication
* Impotence
* Cold feet
* Angina
N:
* Loss of sensation in feet
* Contractures of feet
