Venous Disorders - PVD Flashcards
What are the risk factors for venous disorders?
- hx of blood clots
- family hx
- obesity
- pregnant
- prolonged standing
- hx of ankle injury or immobility
- trauma, illness, surgery
- lifestyle
What is the clincal presentation of venous disorders?
- edema generally in LE’s
- fatigue
- heaviness feeling in LE’s
- hemosiderin staining
- warm on palpation
- ulcers/wounds are common (above ankle)
- frequent infections
Varicose Veins
What is the cause?
dulated tortuous superficial veins
- the most common are the saphenous and tributaries
- possibilty of hemorrhoids
Varicose veins
Intrinsic weakness of the vessel walls will lead to?
- increased intralumal pressure
- congenital weakness
Varicose veins
What are the risk factors?
- females more likely
- pregnant
- obese
- family hx
- prolonged standing
- hx of infection
Varicose veins
What are the sx?
- heaviness
- dull ache
- bulging veins
- local hematomas (small venuoles rupture)
Varicose veins
Stage 1
Reticular veins or spider veins
Varicose veins
Stage 2
Vericose veins or venous nodules
Varicose veins
stage 3
edema of lower leg
Varicose veins
Stage 4
varicose eczema or trophic ulcer
Varicose veins
What are the management strategies?
- conservative
- sclerotherapy (local iv shot)
- endovenous thermal ablation (bring heat to obliterate varicous saph veins)
- surgical
Varicose veins
What are the conservative management techniques?
- compression hose
- feet elevation
- edema managemenet
- avoid prolonged standing
VTE
What are the different categories?
DVT - blood clot found in deep vein of UE or LE
PE - blood clot that traveled to the lung
VTE
What is used to calculate the probability of VTE?
clinical preduction rule and based on risk factors and physical findings
- helps to predict the next steps in medical testing to rile in/out DVT/PE
VTE Pathogenesis
What is apart of the virchow’s triad?
venous stasis
vascular injury
hypercoagulability
VTE Pathogenesis
What is secondary hemostasis?
a trigger of the coagulation cascade
- a series of steps in response to a bleed which is caused by tissue injury
- stays active for 5-6 weeks
VTE Pathogenesis
Where do VTE’s usually occur?
where there’s areas of decreased or mechanically altered blood flow
- VTE can develop weeks after D/C
DVT
What are the risk factors?
- post-op
- obesity
- pregnant and post-partum period
- heart failure or respiratory fail
- tobacco use
- oral contraceptives
- cancer and chemo
- prolonged travel
- trauma
- diabetes, HTN, CVA, SCI
- varicose veins
- increased age
- UE DVT = CVC, PICC lines and pacemakers
DVT
What are the signs and sx?
- unilateral edema
- tenderness and pain in the leg
- warmth and erythema
- low-grade fever
- cognitive changes in elderly
DVT
Where does it usually occur?
Most common in veins of the calves but can happen in the popliteal, femoral or iliac
DVT
Who are most commonly affected by DVT?
women are more likely to develop especially in pregnancy and early post-partum
DVT
What are some diagnosis tools?
- serum d-Dimer (measuring fibrin)
- doppler US
- MRI
- contrast venography
DVT
What is the score interpretation of Wells Clinical Prediction Rule?
greater than 3 = high risk
1-2 = mod risk
lower than 1 = low risk
DVT
What is the simplified score interpretation for the Well’s Criteria score?
DVT likely = 2 or more points
DVT unlikely = less than 2 points
DVT
What is the clinical features needed for DVT?
- venous materail in subclavian or jugular vein
- localized arm pain
- unilateral pitting edema
- alternative diagnosis
DVT
What should not be relied upon?
Homan’s sign
- treat or refer based on the probability of DVT
DVT
What are the treatment indications?
- compression stockings
- anti-coagulation
- 1st DVT dx (usually on rx for 3 mos)
- if can’t anti-coagulate patient then IVC filter is considered
DVT
When should you check with the medical team?
if the patient is not on anticoagulants and has a known DVT and does not have an IVC filter
DVT
if on warfarin, what is normal INR levels?
less than 1.1 in healthy normal NOT on warfarin
DVT
if on warfarin, what is the INR levels of therapeutic range?
2-4 therapeutic range when ON warfarin
DVT
When on warfarin, what is the INR levels for risk of hemorrhage?
greater than 4.5
DVT
When on warfarin, what is the INR levels for increased risk of clot?
less than 2
DVT
What is recommended to avoid eating?
- large amounts of green leafy vegetables with vitamin K
- green tea
- cranberry juice
- alcohol
DVT
What is the guideline for unfractionated heparin?
< 24 hours: no mobility
24-48 hours: consult medical team
.>48 hours: mobilize
DVT
What is the guideline for heparin?
< 3 hours: no mobility
3-5 hours: check with physician
.> 5 hours: mobilize
DVT
What is the purpose of an IVC filter?
placed in the inferior vena cava above the level of diagnosed clot
- to help prevent DVT from going to the lungs
VTE
What score is indicative for a high risk of VTE on the Padua Prediction Score?
greater than or equal to 4
What is the khorana risk score?
low risk = 0 points
intermediate risk = 1-2 points
high risk = > 3 points
what is the score needed to stop anticoagulation?
If the HASBLED score is greater than or equal to 4
HAS-BLED
Condition for H
Hypertension
- uncontrolled
- greater than 160 mmHg
HAS-BLED
Condition for A
abnormal renal function: dialysis, transplant, Cr > 2.26 mg/dL or > 200 umol/L
abnormal liver function: cirrhosis or bilirubin > 2 x normal or AST/ALT/AP > 3 x normal
HAS-BLED
Condition for S
prior hx of stroke
HAS-BLED
Condition for B
Bleeding
- prior major bleeding or predisposition to bleeding
HAS-BLED
Condition for L
Labile INR (unstable/high INR)
- time in therapeutic range < 60%
HAS-BLED
Condition for E
Elderly
- age 65 and older
HAS-BLED
Condition for D
Drug or alchol usage hx (greater 8 drinks/wk)
medication usage predisposing to bleeding
Post thrombotic syndrome
What is the prevalence of development?
- develops in 20-50% with an LE DVT even with anticoagulation
- 8-28% UE DVT
Post thrombotic syndrome
What is the cause?
permanent damage to the valves of the veins and reflex of the blood in the venous system
Post thrombotic syndrome
What does it lead to?
leads to venous hypertension = reduces muscle perfusion which increases tissue permeability
Post thrombotic syndrome
What are the signs and sx?
- chronic aching arm or leg pain
- intractable edema
- limb heabiness
- leg ulcers
- skin changes
- heaviness of the limb affected by DVT
Post thrombotic syndrome
What is disease associated with?
high morbidity and lower QoL
Pulmonary embolism
What is a PE?
clot, most often from DVT
- it breaks off then dislodges and travels through the vena cava
- right heart to the lungs and lodges in a part of the pulmonary vasculature
Pulmonary embolism
What is the prevalence?
common, especially after surgery and trauma prolonged immobility
- can be fatal (40% fatality rate if left untreated)
Pulmonary embolism
What is the presentation?
- dyspnea
- pleutritic chest pain
- hemoptysis
- cough
- syncope
- tachypnea
Pulmonary embolism
How is it diagnosed?
same as for DVT but also EKG, CTA, v/q scans
Pulmonary embolism
How is it treated?
anticoagulation and thrombolytic therapy
Pulmonary embolism
What is the risk score interpretation for Wells Clinical Prediction Rule?
high risk: > 6
mod risk: 2-6
low risk: < 2
What does chronic valve incompetence or venous obstruction leads to?
to extravasion (leaking) of edema into surrounding tissues
What is chronic venous insufficiency?
associated with variscose veins, edema, skin inflammations and hyperpigementations and ulcerations
Chronic venous insufficiency
What are the treatments?
- Treating the edema
- diuretics
- antibiotics (when infection is present)
- compression
- dressing changes
Chronic venous insufficiency
What do most chronic wounds most likely lead to?
lead to an amputation
- one of the most difficult to treat
Chronic venous insufficiency
What are some of the types of compression?
bandage pressure
spiral wrap of LE (50% overlap provides 2 layers)
figure 8 (50% overlap provides 4 layers)
compression garments
Chronic venous insufficiency
What are the options for compression garments?
- graded compression stockings
- Unna boot (zinc oxide paste and gauze boots)
- multilayer bandaging
What do we take into account for venous insufficiency hx?
- can report chronic edema issues
- slow healing
- h/o infections
- h/o varicose veins
What do we take into account for arterial insufficiency hx?
- aching or cramping of distal limbs
- poor wound healing
- limited mobility
What are the special tests for vascular examination?
- capillary refill time
- ABI
- venous filling time / rubor of dependency test
- intermittent claudication test
- Wells’ clinical prediction rules
- DVT clinical practive guidelines
- response to exercise
Difference in vascular wounds
Skin characteristics - arterial
- shiny
- dry
- cool/cold
- loss of hair
- rubor with dependent positioning
- pallor in elevation
Difference in vascular wounds
Skin characteristics - venous
- warm
- pigmentation
- mottling
- thickened
- rough skin
- changes in appearance of skin after wound healing
Difference in vascular wounds
Pain - arterial
positive for pain due to ischemia
Difference in vascular wounds
pain - venous
wounds generally minimally painful
Difference in vascular wounds
Exudate - arterial
Not observable, dry
Difference in vascular wounds
Exudate - venous
commonly seen, oozing
Difference in vascular wounds
Pulses - arterial
can be absent or dimished
Difference in vascular wounds
Pulses - venous
normal
Difference in vascular wounds
Common sites - arterial
toes, feet, distal to malleoli
Difference in vascular wounds
Common sites - venous
above malleoli, distal 1/3 lower leg
Difference in vascular wounds
Wound characteristics - arterial
- small
- defined borders
- punched out
- deep
- tunneling
- dry
- necrotic tissue
Difference in vascular wounds
Wound characteristics - venous
- uneven borders
- shallow
- drainage
- can be large
Cellulitis
What is cellulitis?
bacterial (staphylococcus aureus or streptococcus) skin infection of dermis or subcutaneous tissue
- breaks in skin, splinters, bug bites, incisions, IV sites
- not a vascular disorder but can be confused for a developing venous wound
Cellulitis
What are the sx?
- red area of the skin that tends to expand
- swelling
- tenderness
- pain
- warmth
- occasional open wounds
- fever
- red spots
- blisters
- skin dimpling
Cellulitis
What are the treatment?
- long term antibiotics
- wound care
- reduction of edema
Cellulitis
What can it progress to?
osteomyelitis - infection of the bone
Raynaud’s Disease
What is Raynaud’s disease?
Intermittently affects small arteries and arterioles = decreased blood supply to distal extremity
Raynaud’s Disease
What are the sx?
- cold fingers/toes
- color changes to skin in response to cold or stress
- numbness/tingling in fingers or toes
- stinging/throbbing pain when warming or stress relieved
- ulcers can occur on tips of fingers/toes (severe cases)
Raynaud’s Disease
What are the causes?
- Atherosclerosis
- drugs that cause narrowing of the arteries
- certain autoimmune conditions
- smoking
- repeated injury or usage
Raynaud’s Disease
What are the treatments?
- no smoking
- avoid caffeine
- avoid medications that cause tightening of the blood vessels
- keep the body warm, stop going to the cold, wearing mittens or warmers
- wear comfortable, roomy shoes and wool socks
Buerger’s Disease
What is burger disease?
I mean Buerger’s Disease
inflammation and thrombosis of small and medium sized veins and arteries
- onset is distal to proximal in extremities
Buerger’s Disease
What is the cause?
unknown but possibly smoking
Buerger’s Disease
What is the prevalence?
common in males aged 20-40s
Buerger’s Disease
What are the sx?
- temp and color variance in hands/feet
- pain in hands/feet can be severe (arch of foot)
- painful sores or ulcers hands/feet
- pain during walking in LEs
Buerger’s Disease
What are the treatments?
- no cure for disorder
- stop smoking
- pain management
- improve circulation thru surgery that restores blood flow
