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Phase 2 - General Surgery Placement > Vascular Surgical Presentations > Flashcards

Vascular Surgical Presentations Flashcards

1
Q

how should an acutely painful limb that is cold and pale be treated?

A

it should be treated as acute limb ischaemia until proven otherwise

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2
Q

what are the ‘6 Ps’ of acute limb ischaemia?

A
  • pain
  • pallor
  • pulselessness
  • parasthesia
  • perishingly cold
  • paralysis
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3
Q

what are the common risk factors for acute limb ischaemia?

A

AF, hypertension, smoking, diabetes, recent MI

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4
Q

what imaging should you undertake if you suspect acute limb ischaemia?

A

CT angiogram

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5
Q

at what point does irreversible tissue damage occur in acute limb ischaemia?

A

within 6 hours

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6
Q

how should an acutely painful limb that is hot and swollen be treated?

A

it should be assessed for a DVT

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7
Q

what are other causes of a hot, swollen, painful limb?

A

cellulitis and other MSK related infections that require treatment with antibiotics

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8
Q

what other signs and symptoms would lead you to suspect a DVT?

A

if the pain is localised to the calf

if the pain is associated with calf tenderness and firmness

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9
Q

what are the risk factors for developing a DVT?

A

virchow’s triad

  • family history of pro-thrombotic disease
  • recent immobility (e.g. surgery or flights >5hrs)
  • pregnancy
  • trauma
  • smoking
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10
Q

what is the Wells’ score and how is it used?

A

it is used when one suspects a DVT

a score >1 is an indication for an ultrasound Doppler scan

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11
Q

how do you treat a confirmed DVT?

A
  • therapeutic dose of LMWH (enoxaparin 40mg IV)

- start long-term anti-coagulation

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12
Q

what is important to check for in a patient that attends with an acutely painful limb?

A

check for any signs or a history of trauma as patient may have a fracture

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13
Q

how do you assess for a suspected fracture?

A

check for focal bony tenderness and an inability to weight bear

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14
Q

true or false: neurological pathologies may present as an acutely painful limb

A

true.

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15
Q

what are the categories for neurological causes of limb pain?

A
  • central (MS)
  • spinal (disc herniation)
  • peripheral (infective or traumatic causes)
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16
Q

what are associated signs and symptoms of a patient with a painful limb caused by a neurological issue?

A
  • pain that radiates to the affected region
  • pain that is worse on movement
  • muscle weakness
  • paraesthesia
  • altered reflexes
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17
Q

what is an ulcer?

A

abnormal breaks in the skin of mucous membranes

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18
Q

true or false: most lower limb ulcers have an arterial origin

A

false.

most lower limbs ulcers have a venous origin

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19
Q

what leads to a pressure ulcer?

A

prolonged or excessive pressure over a bony prominence

20
Q

how would one describe a venous ulcer?

A

shallow with a granulated base
irregular borders
located in the ‘gaiter region’ (shins and medial malleolus)

21
Q

how would one describe an arterial ulcer?

A

found distally in pressure areas with well defined borders
small, deep lesions
necrotic base

22
Q

how would one describe a neuropathic ulcer?

A

painless ulcers over areas of pressure, often secondary to joint deformity in diabetics
has a punched out appearance

23
Q

true or false: venous ulcers are highly prone to infection

A

true.

they tend to present with accompanying cellulitis

24
Q

what is the pathophysiology of a venous ulcer?

A

venous outflow obstruction causes poor venous return and venous hypertension.
this leads to a ‘trapping’ of WBCs in the capillaries, which then become activated due to lack of oxygen.
they release inflammatory mediators, injuring the tissue and causing poor wound healing and necrosis

25
Q

what are the risk factors for developing a venous leg ulcer?

A
  • age
  • pre-existing venous problems (e.g. DVT or varicose veins)
  • pregnancy
  • obesity/ physically inactive
  • severe leg trauma
26
Q

what are the clinical features of a venous leg ulcer?

A
  • painful (worse at the end of the day)
  • aching, itching, or bursting sensation will appear before the ulcer forms

on examination there may be:

  • varicose veins and eczema
  • oedema
27
Q

what investigations would you do in a suspected venous leg ulcer?

A

it is a clinical diagnosis

  • a duplex USS to assess where the venous insufficiency is
  • an ABPI to assess for any arterial component to the ulcers and if compression therapy will help
  • swab cultures if you suspect an infection
28
Q

what are the most common areas for venous incompetence to occur?

A
  • sapheno-femoral junction
  • sapheno- popliteal junctions

(tends to occur at perforator)

29
Q

how would you manage a venous leg ulcer?

A

conservative:
leg elevation and increased exercise which promotes calf pump action to aid venous return

intervention:
multi component compression bandaging changed once or twice a week

30
Q

how long does a venous ulcer take to heal?

A

after 6 months of compression therapy

31
Q

true or false: a patient’s ABPI must be greater than 0.6 before any compression bandaging is applied to treat a venous leg ulcer

A

true.

32
Q

why should concurrent varicose veins be treated with surgery in a patient wit a venous leg ulcer?

A

it will improve venous return helping the healing of the venous ulcers

33
Q

what is the pathophysiology of an arterial ulcer?

A

a reduction in arterial blood flow leading to decreased perfusion of tissues and causing poor wound healing

34
Q

what are the risk factors for developing an arterial ulcer?

A

same to those of peripheral arterial disease

  • smoking
  • diabetes mellitus
  • hypertension
  • hyperlipidaemia
  • age
  • family history
  • obesity
35
Q

what are the common clinical features of a patient with suspected arterial ulcer?

A
  • previous history of intermittent claudication or critical limb ischaemia (pain at night)
  • ulcer develops over a long period of time with almost no healing (absence of granulation tissue)
  • signs of vascular disease (skin changes, hair loss, thick nails)

on examination:

  • cold limbs
  • reduced pulses
  • sensation is maintained (unlike neuropathic ulcers)
36
Q

what investigations would you do in a patient with a suspected arterial ulcer?

A
  • ABPI to measure extent of peripheral arterial disease

- duplex ultrasound, CT angiography, MRA to find location of arterial disease

37
Q

what are the measurement indications of an ABPI?

A 
>0.9 = normal
0.9-0.8 = mild peripheral arterial disease
0.8-0.5 = moderate peripheral arterial disease
<0.5 = severe peripheral arterial disease
38
Q

how would you manage a patient with an arterial ulcer?

A
  • refer for a vascular review
    conservative:
  • lifestyle advice e.g. smoking cessation and weight loss
    medical:
  • pharmacological CV risk factor modification (statin and antiplatelet)
  • BP and BM control
    surgical:
  • angioplasty or bypass grafting
  • patients may be offered a skin graft if the ulcer continues to be non-healing
39
Q

what is the pathophysiology of a neuropathic ulcer?

A

occurs as a result of peripheral neuropathy.
there is a loss of protective sensation leading to repetitive stress and unnoticed injuries forming.
often occurs concurrently with vascular disease.

40
Q

what are the risk factors for a neuropathic ulcer?

A
  • diabetes mellitus
  • B12 deficiency

(any condition with peripheral neuropathy)

41
Q

what are the clinical features of a neuropathic ulcer?

A
  • patients have a history of peripheral neuropathy or symptoms of peripheral vascular disease
  • signs of neuropathy (burning/tingling in the legs, muscle wasting)

on examination

  • warm feet and good pulses
  • accompanied peripheral neuropathy (glove and stocking)
42
Q

what investigations would you do in a patient with a suspected neuropathic ulcer?

A
  • blood glucose levels and serum B12 to find cause of neuropathy
  • ABPI +/- duplex to assess for concurrent arterial disease
  • swabs to assess for infection
  • x-ray to assess for osteomyelitis
  • assess extent of neuropathy by testing vibration sense
43
Q

how would you manage a patient with a neuropathic ulcer?

A
  • specialised diabetic foot clinics manage neuropathic ulcers via MDT
  • advise on diabetic control
  • manage cardiovascular risk factors
  • educate on foot hygiene
    ischaemic or necrotic tissue will need surgical debridement or amputation
44
Q

what is Charcot’s foot?

A

a neuropathy where loss of sensation leads to continuous unnoticed trauma and deformity occurring

45
Q

true or false: patients with Charcot’s foot deformity predisposes them to neuropathic ulcer formation

A

true.

46
Q

how do patients with Charcot’s foot present?

A
  • swelling
  • distortion
  • pain
  • loss of function
47
Q

how is Charcot’s foot managed?

A

requires specialist review for consideration of off-loading abnormal weight.
may need immobilisation of the affected joint using plaster

Phase 2 - General Surgery Placement (14 decks)

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