PVD and Vascular Wounds

Question 1

In Maine, what kind of tissue can PTs debride?

Answer 1

They can debride necrotic tissue; no healthy tissue. There should be NO bleeding

Question 2

What are signs of arterial insufficiency?

Answer 2

Dependent rubor
Slow nail growth
Faint pulses, or absent. (e.g. Dorsal Pedal)
Skin is cool, pale, and shiny (atrophic)
Loss of hair

Question 3

How fast to fingernails grow?

Answer 3

3mm / month on average

Question 4

What causes pain during intermittent claudication?

Answer 4

Too little blood flow, usually during exercise. Usually affects the blood vessels in the legs. May progress to pain at rest

Question 5

What is the most significant arterial disease associated with ulcer development?

Answer 5

Atherosclerosis

Question 6

What are warning signs for atherosclerosis, if symptomatic?

Answer 6

Mild - intermittent cluadication
Severe - rest pain
Lying down at night; pain in a dependent position

Risks: age, male, cigs, DM, HTN, hyperlipoproteinemia, elevated WBC

Question 7

What is the difference between IC and lateral stenosis?

Answer 7

During treadmill test (PAD):

IC - 10 mins, pain, but relief w/ sitting. Walks less after incline

LS - 10 mins, pain. Relief w/ sitting. But will walk equal or more when inclined (due to the spine being flexed)

Question 8

Is DM a risk factor for PAD

Answer 8

Yes

More common, earlier onset, more rapid, bilateral.
2:1 in Males with DM

(without DM, 30:1 M:F)

Question 9

Where do arterial ulcers develop?

Answer 9

Distal extremities first

Question 10

What are the characteristics for arterial ulcers?

Answer 10

Edges are well-demarcated
Base of ulcer is pale and dry
Minimal drainage
No granulation tissue present (no blood flow to promote proliferation)
May be area of wet necrosis or a dry scab (you don’t want arterial ulcers to get wet?)
Periwound may be black, gangrenous

Question 11

What is the first step in treating an arterial wound?

Answer 11

See if you can treat the underlying cause first!

Question 12

Are arterial ulcers painful

Answer 12

Usually, yes.

Question 13

Clinical tests for an arterial ulcer?

Answer 13

Peripheral pulses - doppler
ABIs
Rubor of Dependency
Capillary Refill
Venous Refill

Question 14

How do you grade peripheral pulses??

Answer 14

0 - absent
1+ - thready
2+ - weak
3+ - normal
4+ - bounding
post tib and dorsal pedis are most important)

Question 15

How to calculate ABI?

Answer 15

systolic LE / systolic UE

Use HIGHER UE value after testing each arm
Use LE value of the side you want to check
*Can also try exercise ABI
*Check pressure afterwards with a doppler

Question 16

Why is it bad if ABI is > 1.2?

Answer 16

Incompressible arteries. You want it between 0.8-1.0

Question 17

What is triphasic doppler sound?

Answer 17

The result of the combination of ventricular systole, elasticity of the blood vessles, and backflow caused by the closing of the semilunar valves - best

Question 18

Biphasic sounds?

Answer 18

Occurs in more distal blood vessels as the result of ventricular systole and the elasticity of the blood vessels

Question 19

Monophasic sounds?

Answer 19

Occurs when the flow of blood is no longer pulsatile - bad

Question 20

How to test rubor of dependency?

Answer 20

Patient is supine
-Observe plantar aspect of the foot for color

Elevate to 60 degrees (hip flexion with knee extension) for one minute. Foot should not go pale (stop if pain reported)

45-60 sec = mild arterial insufficiency
30-45 = moderate

Question 21

What is dependent rubor?

Answer 21

Reactive hyperemia - dilated vessels get “rush of blood”

Dependent rubor is a fiery to dusky-red coloration visible when the leg is in a dependent position but not when it’s elevated above the heart. The underlying cause is peripheral arterial disease (PAD), so the extremity is cool to the touch.

Question 22

How to test capillary refill?

Answer 22

Observe color of distal great toe, push with enough pressure to blanch

After releasing, return of color should be less than 3 seconds

Question 23

What’s the deal with Venous Refill? How do you test it?

Answer 23

Only valid test of arterial blood flow IF pt doesn’t have venous insufficiency - still relevant for someone with arterial insufficiency

Supine, observe DORSAL aspect of foot for colors / veins
-Elevate to 60 degrees for one minute. Then place patient in dependent position (seated) and WATCH FOR FILL TIME!

20 ( or >30) seconds = arterial insufficiency

Question 24

Lab tests for venous REFILL?

Answer 24

ABIs
Toe-Brachial Index
Transcutaneous partial pressure of oxygen (TcPO2) / Transcutaneous Oxygen Measurement (TCOM)
Doppler Imaging
(Imaging w/ contrast
-Arteriogram (Radiograph)
-Computed tomography angiography (CTA)
-Magnetic resonance angiography (MRA)

Question 25

TcPO2 - what do the results mean?

Answer 25

LEss than 20 mmHg = significantly impaired bloodflow with little to no healing expected Above 30 mmHg = adequate bloodflow for healing Above 40 mmHg = normal

Question 26

How to treat Arterial Insufficency?

Answer 26

``` Walking program (see Bb file) Hyperbaric oxygen - 100% O2 (5x week for 3-4 hours for 1+ months - may need long-term housing) Medical - meds Surgical - stents and bypass grafts ```

Question 27

Benefits of hyperbaric oxygen?

Answer 27

Enhances fibroblast activity Promotes collagen synthesis Neovascularization Increase in tissue O2 is beneficial to leukocytes and acts as antimicrobial would Remimbursed for DFU Stage 3+ and CO poisoning

Question 28

How do you treat Arterial Ulcers?

Answer 28

Protect from pressure (bed rest, off-loading, positioning) Increase blood flow / oxygen - Hyperbaric oxygen - Arterial bypass - Angioplasty and stents Wound care - ISCHEMIC ULCERS SHOULD BE KEPT DRY - Ischemic tissue macerates in water and promotes bacterial growth

Question 29

Arterial Wounds?

Answer 29

High risk of infection If the eschar is dry, stable, and no signs and symptoms of infection: dress and protect with a DRY dressing (e.g. non-adhereant foam) - not broke, don't fix it. If there is significant oxygen perfusion distal to the site indicating adequate blood flow (ABI > 0.8): proceed with DEBRIDEMENT and MOIST wound healing -Never debride if you are not sure what is underneath

Question 30

Dressings for Arterial Ulcers?

Answer 30

Dry, foam non-adhereant if covering stable uninfected eschar Dressings with antimicrobials impregnated desirable due to high-risk of infection in arterial wounds Be careful about using dressings that add moisture or are occlusive as this can increase the likelihood of infection in necrotic tissue

Question 31

What is Venous stasis?

Answer 31

Venous blood flow insufficiency - permanent damage to the vein Compression will help blood flow back to the heart. Can use mechanical debridement? 80% get better Gravity keeps less in foot, veins cannot bring it back, pressure builds. Shallow sore, uneven, inner lower leg near ankle

Question 32

What is the first sign of DVT?

Answer 32

Edema in the ankles at night. Risk factors: overweight, heredity, pregnancy, lots of standing or sitting

Question 33

What is Venous Hypertension?

Answer 33

``` Normal venous pressure is 60-90 mmHg in foot veins (in standing) -Venous hypertension is >90mmHg Causes: -Thombolitic -Obstruction ```

Question 34

What is Chronic Venous Hypertension?

Answer 34

Failure of the system to reduce venous pressure Early signs: Varicosities Late signs: pitting edema - Lipodermatosclerosis / fibrotic tissue - Hemosiderin staining - White plague

Question 35

First complaint of venous insufficency?

Answer 35

Swelling of legs that is relieved with elevation Mechanical insufficiency: -High ambulatory venous pressure Failure of valves, valf mm

Question 36

Characteristics of Venous Ulcers?

Answer 36

Pathogenesis unclear Wounds found on distal, medial 3rd of LE prox to medial malleolus ``` Characteristics: -Irregular shape Shallow Granulation tissue present, pink to red Borders are flat Wet, excessive drainage ```

Question 37

Lab tests for venous insuffiency?

Answer 37

Venous plethysmography - test of venous refill time Venous Doppler scanning Venography

Question 38

Compression therapy for Venous Ulcers?

Answer 38

Short-stretch bandages improve calf-pump during ambulation by containing the muscle against the valves, but MUST have adeqaute arterial blood flow before you compress. Wound care: - Typically need absorptive dressings because of exudate - Foam, calcium alginate, hydrofiber, hydrocolloid This is different than an ACE wrap. An ACE wrap loosens with activity. This is like an extra layer of muscle

Question 39

How do Unna Boots work?

Answer 39

Semirigid dressing of gelatin / zinc oxide / calamine - like a cast. Improves calf pump and reduces edema; can be placed directly on the wound Least expensive, no dressing needed on wound itself - depends on amount of exudate

Question 40

Coban 2?

Answer 40

Easy to put on, can wear own shoes and clothing. 2-layer system (see lab for full details)

Question 41

Profore?

Answer 41

4-layer. see lab for full details

Question 42

What is Intermittent Pneumatic Compression?

Answer 42

Intermittent pneumatic compression is a therapeutic technique used in medical devices that include an air pump and inflatable auxiliary sleeves, gloves or boots in a system designed to improve venous circulation in the limbs of patients who suffer edema or the risk of deep vein thrombosis (DVT) or pulmonary embolism (PE).[1] Indications? Contrainidcations (absolute and relative) - DVT - ABI

Question 43

IS arterial or venous more common?

Answer 43

Venous. 1 in 4 have it

Question 44

How does ambulatory exercise training work for IC?

Answer 44

Walk 5 min at 2 mph at 12% incline - measure arm and ankle pressures ever 2 min until return to baseline or 20 min.

Question 45

What are the goals of this ex program? When do you see benefits?

Answer 45

Relieve IC sx, restore ex capacity, decrease CV disease risk. You will see benefits in 1-2 months *See Bb sheet for full details; likely will be Qs from there

Question 46

Should you have cool downs and warm ups with Ambulatory Exercise Training for Intermittent Claudication?

Answer 46

Yes, 5-10 mins each

Question 47

Does the patient rest in sitting or standing with Ambulatory Exercise Training for Intermittent Claudication?

Answer 47

Either, until pain subsides. Then repeat ex-rest-ex cycles

Question 48

How far into Ambulatory Exercise Training for Intermittent Claudication are you trying to elicit symptoms?

Answer 48

3-5 mins

Question 49

How long is each session for Ambulatory Exercise Training for Intermittent Claudication?

Answer 49

first session = 35 mins -Each session increased 5 mins until 50 mins of intermittent walking is achieved Program continues 2-3 months or until functional goals are met (patient can exercise without supervision)

Question 50

Wait pain level on the VAS do you want to achieve?

Answer 50

8/10.