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Edit Comment Close Premium member Presentation Transcript Slide 1: Peripheral Vascular System ExaminationHistory : History Age and sex Limbs effected Bilateral or unilateral Mode of onset Pain (intermittent claudication or rest pain) Effect of heat and coldcont: cont Paresthesia Impotence Past history Personal history Family historyDefinition of Acute Limb Ischemia: Definition of Acute Limb Ischemia Sudden decrease of arterial limb perfusion causing threat to limb viabilityPatho-pysiology: Patho-pysiology Acute Embolic Ischemia Acute Thrombotic Ischemia An embolus suddenly occludes a relatively healthy arterial tree Atherosclerosis causes progressive narrowing of the arterial tree Stimulates development of collaterals Sluggish flow & rough surface will favor acute thrombosis It usually arrest at arterial bifurcation Aortic bifurcation Iliac bifurcation Femoral bifurcation Popliteal trifurcation An embolus can originate from the heart (MS with atrial fibrillation, MI with mural thrombus) or dilated diseased arteries (aortic aneurism)Clinical Evaluation of Acute Ischemia (Clinical Picture): Clinical Evaluation of Acute Ischemia (Clinical Picture) Symptoms of acute ischemia: Pain : Diffuse foot & leg severe aching pain of acute onset (more acute in embolic ischemia) Pain may diminish in intensity by time if collaterals open improving circulation, or if ischemia progresses causing ischemic sensory loss Coldness is an early symptom Numbness followed by sensory loss (late) Muscle weakness (heavy limb) followed by paralysis (late)Clinical Evaluation of Acute Ischemia (Clinical Picture): Clinical Evaluation of Acute Ischemia (Clinical Picture) History Aim of your questions 1- To know whether these symptoms are of acute ischemia or not (DD of acute ischemia : acute DVT [phlegmasia] , hypo-perfusion states [e.g. heart failure specially if associated with chronic ischemia] 2- To know the severity of acute ischemia (ask about symptoms of different classes of acute ischemia – see later ) 3- To look for the underlying etiology (ask about Rh. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath ., risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia, family history of cardio-vascular disease )The 6 Ps of critical ischaemia: The 6 Ps of critical ischaemia Pallor Pulseless Perishingly cold Paraesthesiae Paralysis PainSlide 9: Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 6 P s Pain : symptom + Pulseless Pale Parathesia Paralysis Inspection COLOR : Early : pale Later : cyanosed mottling fixed mottling & cyanosis Pallor Reversible mottling An area of fixed cyanosis surrounded by reversible mottling Empty veins : compare the Rt. (ischemic) & Lt. (normal) Fixed mottling & cyanosisSlide 10: Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 6 P s Pain : symptom + Pulseless Pale Parathesia Paralysis Palpation Femoral Popliteal Posterior tibial Dorsalis pedis Palpate peripheral pulses, compare with the other side & write it down on a sketch Temperature : the limb is cold with a level of temperature change (compare the two limbs) Slow capillary refilling of the skin after finger pressureSlide 11: Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 6 P s Pain : symptom + Pulseless Pale Parathesia Paralysis Palpation Loss of sensory function Numbness will progress to anesthesia Progress of Sensory loss Light touch Vibration sense Proprioreception Deep pain Pressure sense LateSlide 12: Clinical Evaluation of Acute Ischemia (Clinical Picture) Signs of acute ischemia 6 P s Pain : symptom + Pulseless Pale Parathesia Paralysis Palpation Loss of motor function: Indicates advanced limb threatening ischemia Late irreversible ischemia: Muscle turgidity Intrinsic foot muscles are affected first, followed by the leg muscles Detecting early muscle weakness is difficult because toes movements are produced mainly by leg muscles PostgraduatesArterial vs venous ulcers: Arterial vs venous ulcers VENOUS ARTERIAL Gaiter areas, 20% lateral Pressure areas (e.g. Malleoli , heel) Irregular margins Regular ‘punched’ out margins Base often pink and granulating under green slough Sloughy (green) or necroti c (black) with no granulation Skin changes ( lipodermatosclerosis ) No venous skin changes Full, usually varicose veins Empty veins with ‘guttering’ on elevation Warm Cold Oedema No oedema Pulses present Pulses absentOverview: Overview Introduction Inspection Palpation Auscultation Presenting the findingsIntroduction: Introduction You (name, role) Confirm patient details (name, age, DOB) Consent Expose (lying, lower arms and legs)General Inspection: General Inspection Color changes Signs of ischemia Thining of skin, diminshed growth of hairs, loss of subcutaneous fat, shininess, trophic changes in nails, and ulceration Buerger’s postural test Capillary filling time Venous refilling In established gangrene, extent, type, line of demarcationBurguer’s test: Burguer’s test Part 1: Raise legs 45degrees and hold 1-2mins Part 2: Sit patient down and ask them to hang their legs over bed (90degrees) What would happen in ischaemia?Palpation: Palpation Skin temperature Capillary refilling Venous refilling Cold and warm test Cross leg test Elevated arm test Allens testSlide 20: Costoclavicular compressive manoeuvre Hyperabduction manoeuvre Palpation of the vessels i.e pulsation in the upper and lower limb including carotid and comparison Sensations (neurological) Lymph nodesAuscultation: Auscultation Femoral Aortic Renal CarotidsCompleting the examination: Completing the examination Ankle/brachial pressure index What happens in ischaemiaPresenting the findings:: Presenting the findings: “I examined Mr(s) X, a ...-year old lady/gentleman. The patient was calm, comfortable and conscious at rest. There were no parephenalia suggestive of vascular disease, or peripheral stigmata of vascular disease.”Slide 24: On inspection there were no ulcers, skin changes, hair loss, scars or pallor. On palpation, pulses were normal and the temperature and sensation in the legs were normal. Berger’s test was normal. On auscultation, there was no evidence of bruits.Venous System: Venous System Legs whilst standing and supine Inspection- long saphenous or short saphenous? Palpation (temperature) Elevate limb to 15 degrees and note the rate of venous emptying Trendelenberg testTrendelenberg test: Trendelenberg test Sit patient on edge of examination couch Elevate limb, and ‘milk’ the leg Press thumb over saphenofemoral junction Maintain pressure. Tell patient to stand Quick refilling competent valve You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.