Peripheral vascular examination and ABPI Flashcards
When is a PVS clinically relevant?
Common cause of PVD = conditions accelerating the effect of atherosclerosis - e.g. hypertension, hypercholesterolaemia and diabetes. As well as lifestyle habits that do the same e.g. smoking
PVD = blood flow occluded/reduced
In atherosclerosis the blood flow is turbulent - a bruit audible with a stethoscope
What is ABPI and how is it measured?
ABPI = ankle/brachial pressure index
you use a doppler USS (as reduced BF means steth may not work)
it assesses peripheral arterial circulation
The ratio between the systolic pressure in the foot and that in the arms (foot:arms) is the ankle/brachial pressure index - its a measure of the extent of arterial obstruction
doppler = BF effect on reflected soundwaves to audible output or graphical waveform. used to locate pulses, obtain abpi and assess some venous problems
How do you introduce yourself, prepare and generally inspect in a PVS examination?
NB: in PVS upper limb = hands and arms, lower limb = abdomen (aorta), legs and feet - ALWAYS compare both sides
- Introduce self w/full name and role, check patients name.
- explain will need to examine their hands, arms, feet, legs and abdomen: they will need to undress to be able to do this - blanket to cover. Offer a CHAPERONE, obtain consent.
- Ask if patient has any pain and if so where it is.
- Clean hands, position patient on bed @45*. - Gather equip - steth
general inspection:
Do they look well? obvious amputation?
around the bed: equipment e.g. prosthesis, wheelchair or medications?
How do you inspect and examine the upper limbs in a PVS exam?
Inspection:
Scars: (?previous surgery)
Hair distribution: (wont grow if no circulation; ?asymmetry)
Colour: ?pallor or cyanosis, well perfused?
Ulcers ?on fingers esp
Gangrene - chronically inad BS - tissue death; if dry gangrene = black and shrivelled.
[Wet gangrene = assoc. w/infection. If untreated = proximal spread and lead to septicaemia and death]
Palpation of hands and arms:
-Temperature (asses with back of hand and compare both sides)
- Capillary refill time (<2sec @room temp is norm)
- Pulses:
brachial artery pulse
Radial pulse
?regularity as irreg = AF which is a cause of emboli and limb ischaemia
BP - measure BP if not already done so in CVS exa
How do you inspect and palpate the aorta in a PVS exam?
Inspection of the abdomen (lie the patient flat
head supported by pillow)
= Look carefully for scars suggestive of previous vascular surgery: inguinal region (access point for endovascular procedures e.g. for aneurysms)
- Look for visible pulsations
Palpation of the aorta
[Position the fingers of both hands on either side of the mid-line, midway between the
xiphisternum and the umbilicus.]
In a slim patient or volunteer, it is not unusual to feel a pulsatile aorta (pushing upwards). An aneurysm is
expansible - your fingers should be pushed upwards
and outwards.
- pulsatile vs expansile can be hard to detect- most clinicians will confirm their suspicion with imaging (eg ultrasound scan)
Do NOT press too hard if you suspect an aneurysm– danger of rupture.
How do you inspect and palpate the legs and feet in PVS?
Inspection of the legs and feet (same for arms: SHUCG)
- Scars suggestive of previous vascular surgery.
- Hair distribution: Look for asymmetry, wont grow if poor circulation
- Colour:
Is there any pallor or cyanosis?
- Ulcers
: Look between the toes and pressure points on the plantar aspect and the heel. These are often multiple.
Gangrene:
as for upper limbs
Palpation of the legs and feet
- Temperature: Assess with the back of your hand
and compare both sides
= Capillary refill time
in toes: ≤2sec is regarded as normal at room temp.
Pulses
Femoral [mid inguinal point (mid way between the pubic symphysis and the ASIS).]
NB: position can vary
Popliteal [deep in the midline in the popliteal fossa, hook the hamstring tendons out
of the way with the index fingers and use the other three fingers to feel for the pulse.]
Posterior tibial [usually just posterior (or sometimes posterior and inferior) to the medial malleolus.]
Dorsalis pedis [lateral to the extensor hallucis longus tendon, between the bases of 1st and 2nd metatarsals]
How do you auscultate in a PVS and closure?
Auscletate:
Use the diaphragm of the stethoscope. You will hear nothing over a normal artery, bruits
(swooshing sound
s) over a partial obstruction and nothing over a completely obstructed
artery.
- Listen over the aorta, and the femoral artery.
- Listen over any abnormal swellings you may have found.
Closure Thank the patient, tell them they may get dressed and ensure they are comfortable. Clean your hands and your stethoscope Record or report the finding
how do you introduce and prepare for ABPI?
Introduction and preparation.
Introduce yourself by giving your full name and role.
Check your patient’s name
Explain that you need to measure the pressures in the arm and leg using a special
probe and cuff to apply some pressure. They will need to expose the arms and lower
legs.
Obtain consent
Ask if the patient has any pain and if so where it is.
Clean your hands
Position your patient on the bed: lying flat, head supported by a pillow
Collect equipment- Doppler and gel,
sphygmomanometer (BP measurer), calculator
What is the procedure of ABPI?
Procedure
Place correct size sphygmomanometer cuff in normal position on upper arm.
Palpate the radial or brachial pulse.
Put ultrasound coupling gel over radial or brachial pulse.
- Lightly place probe at an angle of 45–60º
to the artery.
Inflate the cuff to above systolic pressure (no flow → no signal).
Get systolic BP: Deflate noting the pressure
at which the Doppler signal is first heard
Place cuff over lower calf above malleoli.
Palpate Posterior Tibial and Dorsalis Pedis pulses.
Measure systolic pressure in BOTH arteries with Doppler in the same way. e.g. Inflate the cuff to above systolic pressure (no flow → no signal).
Get systolic BP: Deflate noting the pressure
at which the Doppler signal is first heard
Closure: Thank the patient,
tell them they may get dressed and ensure they are comfortable. Clean your hands and your stethoscope
How do you calculate and interpret ABPI?
Calculation and
Interpretation:
Use the highest of the 2 foot artery readings.
Calculate ankle/brachial index as:
ABPI = Highest foot systolic BP /
Brachial systolic BP
Normal: >1.0 [e.g. should be normal that the foot is slightly higher BP than brachial]
Intermittent claudication: 0.5-0.95
Rest pain: 0.3-0.5
Critical ischaemia: <0.2
Please note, however, that in arterial disease due to diabetes mellitus, the
ABPI results may
be artificially raised (e.g. more to normal) due to the arteries being less compressible due to wall calcification.
What may you see on inspection of the patient positioning them standing in a PVS - on the venous aspects?
(FLOPP VS EU)
Inspection:
Superficial Varicose veins. These are dilated and tortuous veins. Is the distribution in the long (medial leg) or short saphenous territories (posterior calf)? Are they symmetrical or asymmetrical?
(Dilated none varicose veins may be significant when considering whether DVT is present)
Scars: Following surgery recurrences of varicose
veins is not uncommon.
Port-wine stains.
In the presence of varicose veins this deep purple discolouration
suggests an underlying arterio-venous malformation (especially younger patients)
causing elevated venous pressure.
venous Flares -small dilated veins are often seen around the ankle and are
usually associated with incompetence in the calf perforator veins.
shape- e.g. Lipodermatosclerosis- In chronic venous hypertension the soft
subcutaneous tissue around the lower leg/ankle is often replaced by thick fibrous tissue, a consequence of inflammation and fibrin exudation. In time this forms a hard layer (lipodermatosclerosis) and the leg takes on the shape of an inverted bottle with
a narrow ankle below and soft oedematous limb above.
Oedema.
This is caused by transudation of fluid across capillaries due to venous
hypertension. It is often also related to the presence of varicosities.
Inflammatory changes. Look at the area around any varicosities for signs of
inflammation which may be suggestive of phlebitis (vein wall inflam).
Pigment changes. Look particularly at the area above the medial malleolus forbrown pigmentation due to the deposition of haemosiderin–
a breakdown product of
haemoglobin in transuded red blood corpuscles.
venous Eczema.
This is a form of dermatitis particularly seen over pigmented
areas. It is usually very itchy and if the patient succumbs to scratching it then it may
result in ulceration.
venous Ulcers. These occur as a result of poor nutrition of the fibrotic subcutaneous
tissue and scratching of the dermatitis. Initial epithelial damage leads to ulceration.
They occur especially above the medial malleolus but may be large and involve the
whole of the gaiter area (instep to above anke).
Any Unilateral leg swelling? - one of the clinical features associated with DVT
How do you palpate in peripheral venous examination?
Palpation (with the patient still standing): Check for tenderness over the deep and superficial veins. This may indicate phlebitis, thrombophlebitis or deep vein thrombosis. Feel around the ankle for oedema and lipodermatosclerosis
Check for
fascial defects (herniations) at medial tibial border (from incompetent perforators, which are kind of deep to greater saph down medial leg)
- Feel SFJ for saphenovarix (dilated SFJ) and ask the patient to cough. If the SFJ
valve is incompetent you will feel a thrill.
Tap test
(frequently unhelpful)
Place fingers over SFJ (saphenofemoral juction) and tap distally over varices. A thrill will be felt if the valves
are incompetent due to a continuous column of uninterrupted blood.
Tourniquet’s test for perforator incompetence
(lie the patient flat):
With the patient supine raise the leg to empty the veins.
Apply the tourniquet high on the thigh and ask patient to stand up.
If veins do not fill up, then incompetence is above level of tourniquet at level of SFJ.
If veins fill up, then incompetence is below level of tourniquet.
Repeat with the tourniquet just above the knee to test the MTP and below the knee to test the SPJ (saphenopopliteal).
Hand-held Doppler test for SFJ and SPJ incompetence
More accurate than the above tests and useful in outpatients.
Place Doppler probe at site SFJ or SPJ and listen whilst applying calf compression with
the other hand. On release you will hear reflux lasting 1-2 seconds if the valve is
incompetent.
Other examinations
It may be appropriate to examine the abdomen, female pelvis, male external genitalia
and digital rectal examination and testes in men to check for a mass which might be
obstructing the pelvic veins or inferior vena cava.
Peripheral arterial system. Venous ulcers may be complicated by poor nutritional supply.
Inspect the legs for any signs associated with arterial insufficiency, palpate the pulses
and measure the ABPI.
Conclusion
What is the main venous pathology?
Venous pathology
Although both the superficial and deep systems can be affected by valve failure or
thrombosis, they present very differently.
Superficial venous system
Valve failure
results in venous reflux and the common problem of unsightly varicose veins which can ache, throb and bleed heavily from minor trauma.
With time, changes to the skin occur and approximately 3% of patients with superficial venous reflux will progress to ulcer formation.
Thrombosis can occur in the superficial system e.g. after venous cannulation.
This tends not to be serious but the thrombosed vein can become inflamed resulting in a
tender thrombo-phlebitis, often with systemic upset.
Inflammation in the superficial veins (
phlebitis)can also occur without thrombosis.
Deep vein system Failure or absence of valves
in the deep venous system usually results in a more severe clincal picture. As well as a tendency to cause superficial varicosities, pati ents develop
lower limb swelling, more rapidly developing skin changes and ulceration.
Thrombosis
occurring in the deep veins ( DVT ) results a serious clinical condition with the
potential for clot to dislodge resulting in a life threatening pulmonary embolus. PE occurs in
about 50% of patients with a proximal DVT (above knee) and in about 5% with distal DVT
(below knee).
A vein occluded by thrombosis may recanalize but unfortunately its valves will be rendered
incompetent resulting in
deep venous insufficiency.
