Vascular 2 Flashcards
what classificatin system is used for peripheral arterial disease
Fontaine classification
Describe the fontaine classification system
- Stage 1: Asymptomatic
- Stage 2: IC
- Stage 3: Rest pain
- Stage 4: Ulceration/ gangrene
How do you do a peripheral arterial examination
- Introduce yourself
- ask if they have any pain
- are you comfortable
- look at the room
- expose your patient from the umbillicus to the toes - but being in an exam you wont
- make sure the legs are down on the couch
- say what you can see
- say something about the symmetry of the legs - swelling? dressings? scars? hair distribution changes? discolouration? muscle wasting(inner aspect of thighs the muscle will be thinner)?dryness? ulcers?
- look at the nails and how the quality of the nails are - brittleness is a sign of peripheral vascular disease
- start with temperature - cool legs are associated with more vascular problems
- run the back of the hands all the way down
- sometimes the leg can be hotter than normal
- do the capillary refill - press on the end of the halux and for 5 seocnds - let go after the 5 seconds and watch how long it takes for the colour to return - need it to return within 2 seconds
- then examine the pulses - abdominal aortic aneurysm- lie the patient down and touch on the tummy and press on it - tell them that it will be uncomfortable
- look for a pulsation in 3 directions
- femoral pulses in the groin
- popliteal artery - relax the hamstring muscles
- dorsal pedis pulse
- posterior tibial pulse – do them at the same time
- if they have vein issue they are best assessed standing up
What is acute ischaemic limb
- Rest pain for less than two weeks requiring analgesia • And/or ulceration
- And/or gangrene
- Ankle pressure < 50mmHg
- Toe pressure ( in diabetics ) < 30 mmHg
What are the causes for acute ischaemia limb
Thrombosis (60%) acute on chronic • Atherosclerosis • Popliteal aneurysm • Graft occlusion • Thrombotic conditions (PRV)
Embolism (30%) acute • AF (80%) • Mural thrombosis • Vegetations • Proximal aneurysms and plaques
what are the 6ps that you should check in acute ischaemia limb
- Pain
- Pallor
- Perishingly cold
- Pulseless
- Paraesthesia
- Paralysis
describe the progression of acute ischaemia in the limb
0-6 hrs: Marble white leg
• Intense vasospasm of distal arterial tree
• Emptying of veins
6-12 hrs: Mottled leg
• Vasodilatation in response to smooth muscle hypoxia
• Fills with deoxygenated blood
• Still blanches
12 hrs +:Irreversible ischemia
• Stagnant blood coagulates and thrombus propagates
• Capillary rupture causing fixed staining
• Tense muscles
• Blistering
How do you classify actue limb ischaemia
Category 1
- not immediately threatened
- no sensory loss
- no muscle wekaness
- audible arterial doppler
- audible venous doppler
Category IIa
- salvable if prompt treatment
- minimal sensory loss in the toes
- no muscle weakness
- inaudible arterial droppler
- audible venous doppler
Category IIb
- Salvable if immediate treatment
- moderate sensory loss plus pain
- mild/moderate muscle weakness
- inaudible arterial doppler
- audible venous doppler
Category III
- major tissue loss or permanent nerve damagae inevitable
- profound sensory loss or anaesthetic
- profound muscle weakness/paralysis
- inaudible arterial doppler
- inaudible venous doppler
in Acute limb ischaemia describe the differences between a viable leg, threatened leg and irreversible
Subcritical: Viable leg
• Reduced capillary refill
• No neurological deficit
• Audible arterial HHD signal
Critical acute ischaemia: Threatened leg
• Partial neurological deficit
• Inaudible signals on HHD
Irreversible acute ischaemia: • Absent capillary refill • Complete neurological deficit • Tense muscles • No doppler signal
What investigations do you carry out for acute limb ischaemia
- Blood
- ECG
- CXR
- Echo
- Imaging of arterial tree
