Peripheral Vascular PD

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Author:
Aulockhart
ID:
200192
Filename:
Peripheral Vascular PD
Updated:
2013-02-13 00:50:20
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Peripheral Vascular
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Description:
Peripheral Vascular physical notes
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  1. Quick up stroke and full vl. {HTN, anxiety}
    Hyperkinetic Pulse
  2. – Duroziez Murmur - heard across femoral artery simultaneous with “Collapsing” pulse.
    Corrigan's Pulse
  3. Capillary pulsations in nail-bed. {Aortic Insufficiency}
    Quincke's Pulse
  4. Decreased contractility => Large Pulse then small pulse. (Poor prognosis)
    Pulsus Alternans
  5. decrease in amplitude and increase in frequency during inspiration.
    Pulsus Paradoxus
  6. Temporary weakening of lower extremities due to arterial insufficiency.
    Intermittent Claudication
  7. Atherosclerosis Ab Aorta. dec flow to lower extremities leading to impotence.
    Leriche's Syndrome
  8. No pulse in arms, due to progressive obliterative arteritis.
    Takayasu's Disease
  9. W/ Atrial Fibrillation + Tachycardia. radial pulse not equal to apical pulse.
    Pulse Deficit
  10. symmetric, spindle-shaped expansion. Involves entire circumference
    Fusiform aneurysm
  11. out-pouching on one side only
    Saccular aneurysm
  12. separation of arterial wall layers that fills with blood.
    Dissecting aneurysm
  13. blood escapes into connective tissue, outside of arterial wall
    False aneurysm (pseudo-aneurysm)
  14. Men 50-70yrs, {atherosclerosis, infection, HTN}, Pain, Dyspnea, hoarseness, dysphagia
    Distended neck veins & edema of head or arms.
    Dx?
    Tx?
    • Thoracic Aortic Aneurysm
    • Dx: CXR, Transesophageal echocardiogram, CT scan
    • Tx: Control HTNSurgical repair – Resection and replacement with graft – Endovascular graft
  15. White, Old, Men, {atherosclerosis, HTN, congenital weakness in vessels}, Mostly infrarenal, Pain = Abdominal or low back
    Diminished = femoral / distal pulses

    Pulsatile mass, upper & middle abdomen (80% palpable)
    • AAA
    • Dx studies
    • • Abdominal ultrasound, CT scan
    • Medical Management
    • • If < 5cm = ultrasound /6 months
    • • If > 5cm = Surgery –> Resection and replacement with a graft – Endovascular graft
  16. RF (Arterial Occlusive Disease)
    • Atherosclerosis • Trauma • Vasospasm • Embolism / thrombosis • Inflammation
    • Autoimmune disorders • Obesity • Smoking
    PVD
  17. Intermittent claudication “hallmark”
    Pain at rest (develops as disease progresses)
    • Extremity = cool to touch
    • Peripheral pulses = Weak or absent
    • Extremity = Rubor & cyanosis if dependent & pallor if elevated.
    Chronic Arterial Insufficiency/Occlusion

  18. Exam findings? Chronic Arterial Insufficiency/Occlusion
    • Hypertrophied nails
    • Dry skin
    • Sparse hair
    • Paresthesias
    • Ulcerations/ gangrene of digits
    • Bruits over stenosed vessels
  19. Dx Studies CAI/O 
    - ? normal, mild, severe ABI
    - ? Formula ABI
    - ? Other Dx tests
    • Dx Studies
    • 0.50 - 0.95 = mild to moderate insufficiency
    • < 0.25 = severe
    • 1.0 = normal
    • ABI = Ankle Pressure/ Brachial pressure
    • (BUERGER’S ANGLE)
    • (BUERGER’S TEST)
    • • Duplex ultrasound
    • • Exercise testing
    • • Arteriogram angiography
  20. Tx Chronic Arterial Insufficiency/Occlusion
    • Life style modifications
    • Trental (pentoxifylline)
    • Pletal (cilostazol)
    • Surgical • CLiRPath • Endarterectomy • Bypass grafting • Angioplastyand stent • Amputation
  21. • Pain • Pulselessness • Pallor • Paresthesia • Poikilothermia • Paralysis 
    Cause: Trauma, Embolus, Thrombosis
    Acute Arterial Occlusion
  22. DX & TX Acute Arterial Occlusion
    • Dx Duplex ultrasonography • Arteriography
    • Tx: Heparin drip • Embolectomy • Thrombolytic agents • Amputation
  23. women 16-40 yrs. Small arteries & arterioles of hands and feet constrict or vasospasm. Induced by cold, stress, caffeine, nicotine.
    Sx?
    Raynaud’s Disease - Coldness, pain or numbness, pallor, cyanosis of fingers & toes.
  24. Tx: Raynaud’s Disease
    • CaCB- Norvasc (amlodipine), Procardia (nifedipine)
    • Alpha AdRB- Prazosin (Minipress), Doxazosin (Cardura)
    • Nitrates
  25. What do you avoid with Raynauds dz
    • smoking
    • cold
    • stress 
    • ETOH
    • limit caffeine and chocolate
  26. – Claudication with exercise in arches of feet
    – Digital pain which may be constant
    – Rubor or cyanosis of feet when dependent
    – Absent or decreased pedal or radial pulses
    – Ulcerations and gangrene common
    Thromboangiitis Obliterans (Buerger’s Disease)
  27. Buerger's Dz
    Dx?
    Tx?
    • Dx- Duplex US, arteriogram & biopsy vessels
    • Tx- Improve circulation – Relieve pain – Avoid injury & infection – Amputation if gangrene
  28. Avoid elevation of stump after 24 hrs
    Amputation
  29. • Inflammation or vasculitis of small and medium sized arteries and veins in the extremities
    • Thrombus formation occurs and occludes vessels, Cause is unknown
    Thromboangiitis Obliterans
  30. Abnormally dilated tortuous veins
    Varicose Veins (Varicosities)
  31. • Swollen, dilated, tortuous veins
    • Dull aching
    • Muscle cramps
    • Increased muscle fatigue
    • Ankle edema
    • Varicosities
    • DX- duplex US
    • Tx- Ligation of veins • Sclerotherapy • Laser therapy
  32. Management After Vein Ligation
    • Routine post-op, Bed rest 24hr
    • Foot elevated, compression stockings
    • Leg exercises, Monitor Paresthesias
    • Avoid lotion & avoid standing for long periods of time, Mild analgesics
  33. Virchow’s Triad
    • Venous stasis – reduced blood flow
    • Injury to intimal lining – creates site for clot
    • Hypercoagulability – increased clotting factor
  34. Venous duplex scanning
    D-dimer test (fibrin degradation products) 
    < 300 ng/ml indicates hypercoagulability
    Venous Thrombosis (DVT, PTE, DIC)
  35. Complications of Venous Thrombosis
    • Pulmonary embolus • Venous insufficiency • Venous stasis ulcers • Edema
  36. Swelling or edema of extremity
    Tenderness
    +Homan’s sign 
    Pulmonary embolus signs – CP – Hemoptyosis – Dyspnea – Apprehension – Hypotension
    • Heparin
    • (LMW) Heparin (Lovenox)
    • Coumadin (warfarin)
    • Urokinase, Streptokinase, Activase
    • Plication filter
  37. DVT Tx's that need to monitor PTT, PT, Platelets and their antidotes.
    • PT – 1.5 - 2.5 times control – (INR) - 2.0-3.0
    • - Coumadin - Vit K is antidote 
    • PTT, Platelets
    • - Heparin - Protamine sulfate is antidote
    • - LMW

  38. Active or passive leg exercises
    • Intermittent pneumatic compression devices
    • Compression stockings
    • Encourage post-op deep breathing
    • Avoid using pillows under knees
    • Elevate foot of bed
    • Encourage walking ASAP post-op
    • Don’t cross legs
    • Pharmacologic to reduce hypercoagulability
    • Adequate hydration
    • Stop smoking
    Preventive Measures For Venous Thrombosis and Thrombophlebitis
  39. Swollen limb
    Dry, itchy, coarse
    Brownish skin on lower extremity above ankles
    Stasis ulcers above ankles
    Chronic Venous Insufficiency
  40. Preventive Measures For Venous Thrombosis and Thrombophlebitis
    • Active or passive leg exercises
    • Intermittent pneumatic compression devices
    • Compression stockings
    • Encourage post-op deep breathing
    • Avoid using pillows under knees
    • Elevate foot of bed
    • Encourage walking ASAP post-op
    • Don’t cross legs
    • Pharmacologic to reduce hypercoagulability
    • Adequate hydration
    • Stop smoking

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