PVD and Vascular Wounds Flashcards
In Maine, what kind of tissue can PTs debride?
They can debride necrotic tissue; no healthy tissue. There should be NO bleeding
What are signs of arterial insufficiency?
Dependent rubor Slow nail growth Faint pulses, or absent. (e.g. Dorsal Pedal) Skin is cool, pale, and shiny (atrophic) Loss of hair
How fast to fingernails grow?
3mm / month on average
What causes pain during intermittent claudication?
Too little blood flow, usually during exercise. Usually affects the blood vessels in the legs. May progress to pain at rest
What is the most significant arterial disease associated with ulcer development?
Atherosclerosis
What are warning signs for atherosclerosis, if symptomatic?
Mild - intermittent cluadication
Severe - rest pain
Lying down at night; pain in a dependent position
Risks: age, male, cigs, DM, HTN, hyperlipoproteinemia, elevated WBC
What is the difference between IC and lateral stenosis?
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)
Is DM a risk factor for PAD
Yes
More common, earlier onset, more rapid, bilateral.
2:1 in Males with DM
(without DM, 30:1 M:F)
Where do arterial ulcers develop?
Distal extremities first
What are the characteristics for arterial ulcers?
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
What is the first step in treating an arterial wound?
See if you can treat the underlying cause first!
Are arterial ulcers painful
Usually, yes.
Clinical tests for an arterial ulcer?
Peripheral pulses - doppler ABIs Rubor of Dependency Capillary Refill Venous Refill
How do you grade peripheral pulses??
0 - absent 1+ - thready 2+ - weak 3+ - normal 4+ - bounding post tib and dorsal pedis are most important)
How to calculate ABI?
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
Why is it bad if ABI is > 1.2?
Incompressible arteries. You want it between 0.8-1.0
What is triphasic doppler sound?
The result of the combination of ventricular systole, elasticity of the blood vessles, and backflow caused by the closing of the semilunar valves - best
Biphasic sounds?
Occurs in more distal blood vessels as the result of ventricular systole and the elasticity of the blood vessels
Monophasic sounds?
Occurs when the flow of blood is no longer pulsatile - bad
How to test rubor of dependency?
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
What is dependent rubor?
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.
How to test capillary refill?
Observe color of distal great toe, push with enough pressure to blanch
After releasing, return of color should be less than 3 seconds
What’s the deal with Venous Refill? How do you test it?
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
Lab tests for venous REFILL?
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)
TcPO2 - what do the results mean?
LEss than 20 mmHg = significantly impaired bloodflow with little to no healing expected
Above 30 mmHg = adequate bloodflow for healing
Above 40 mmHg = normal
How to treat Arterial Insufficency?
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
Benefits of hyperbaric oxygen?
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
How do you treat Arterial Ulcers?
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
Arterial Wounds?
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
Dressings for Arterial Ulcers?
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
What is Venous stasis?
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
What is the first sign of DVT?
Edema in the ankles at night.
Risk factors: overweight, heredity, pregnancy, lots of standing or sitting
What is Venous Hypertension?
Normal venous pressure is 60-90 mmHg in foot veins (in standing) -Venous hypertension is >90mmHg Causes: -Thombolitic -Obstruction
What is Chronic Venous Hypertension?
Failure of the system to reduce venous pressure
Early signs: Varicosities
Late signs: pitting edema
- Lipodermatosclerosis / fibrotic tissue
- Hemosiderin staining
- White plague
First complaint of venous insufficency?
Swelling of legs that is relieved with elevation
Mechanical insufficiency:
-High ambulatory venous pressure
Failure of valves, valf mm
Characteristics of Venous Ulcers?
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
Lab tests for venous insuffiency?
Venous plethysmography - test of venous refill time
Venous Doppler scanning
Venography
Compression therapy for Venous Ulcers?
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
How do Unna Boots work?
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
Coban 2?
Easy to put on, can wear own shoes and clothing. 2-layer system (see lab for full details)
Profore?
4-layer. see lab for full details
What is Intermittent Pneumatic Compression?
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
IS arterial or venous more common?
Venous. 1 in 4 have it
How does ambulatory exercise training work for IC?
Walk 5 min at 2 mph at 12% incline - measure arm and ankle pressures ever 2 min until return to baseline or 20 min.
What are the goals of this ex program? When do you see benefits?
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
Should you have cool downs and warm ups with Ambulatory Exercise Training for Intermittent Claudication?
Yes, 5-10 mins each
Does the patient rest in sitting or standing with Ambulatory Exercise Training for Intermittent Claudication?
Either, until pain subsides. Then repeat ex-rest-ex cycles
How far into Ambulatory Exercise Training for Intermittent Claudication are you trying to elicit symptoms?
3-5 mins
How long is each session for Ambulatory Exercise Training for Intermittent Claudication?
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)
Wait pain level on the VAS do you want to achieve?
8/10.
