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The Vascular Exam

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The Vascular Exam Jason Davis, MD * * * * * * * * * * * * Before the Exam Obtain history Acute vs. Chronic symptoms Distribution of symptoms Level(s) of extremity ... – PowerPoint PPT presentation

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Title: The Vascular Exam


1
The Vascular Exam
Jason Davis, MD
2
Before the Exam
  • Obtain history
  • Acute vs. Chronic symptoms
  • Distribution of symptoms
  • Level(s) of extremity pain, etc.
  • Aggravating, Relieving factors
  • Activity/rest, elevation/dependence
  • Co-morbid conditions, vitals

3
Basic Anatomy to Know
4
Basic Anatomy to Know
5
Basic Anatomy to Know
6
Elements of Vascular Exam
  • Inspect, Palpate, Auscultate
  • Skin pallor/rubor, mottling/ cyanosis,
    temperature, atrophy, hair distribution
  • Motor function and sensory exam
  • Tissue loss, ulcerations
  • Pulse /- doppler exam
  • Always compare each w/ contralateral

7
Elements of Vascular Exam
8
Vascular Exam tips
  • Doppler signals are NOT Pulses
  • Palpable pulses include carotid, brachial,
    radial, ulnar, femoral, popliteal, dorsalis
    pedis, posterior tib
  • Bruits vs. Thrills Audible vs. Palpable
  • Characterization of Pulses
  • Character (bounding, thready), Rate, Rhythm
  • Characterization of Doppler Signals
  • Triphasic, Biphasic, Monophasic

9
Trauma / Hypovolemia
  • If you can palpate
  • Radial pulse, then SBP is gt70 - 80
  • Femoral Carotid, then SBP gt50 - 70
  • Carotid only, then SBP gt40 - 60
  • NEVER rely on pulses alone for hypovolemia
    assessment

10
Lower Extremity Ulcers
  • Arterial (PAD)
  • Distal (often at toes), painful, pale
    granulation,
  • Assoc w/ atrophy, hairless/shiny skin,
    rubor-pallor
  • Venous (VI)
  • Lower third, medial malleolus, elevation relieves
  • Assoc w/ edema, larger, irregular, moist base
  • Diabetic
  • Pressure offloading, footwear, self-checks

11
Common Vascular Problems
  • Peripheral arterial disease
  • Thrombotic (DM, atherosclerosis)
  • Embolic (atrial fibrillation, Aneurysms)
  • Venous insufficiency
  • DVT, thrombophlebitis
  • Carotid artery stenosis
  • Compartment Syndrome
  • Trauma

12
Compartment Syndrome
  • Leg compartments
  • Lower Anterior, Lateral, Superficial Deep
    Posterior
  • Upper Anterior (extensor), Medial (adducter),
    Posterior (sciatic n.)
  • 6 Ps indicating ischemia
  • Pain
  • Paresthesias
  • Palor
  • Pulselessness
  • Poikilothermia
  • Paralysis

13
Clinical Scenario 1
  • Routine 5pm ED consult for cellulitis.

14
Clinical Scenario 1
  • Routine 5pm ED consult for cellulitis.
  • You see before leaving within your hrs
  • On arrival, 78yo male w/ DM, CAD, tobacco
  • Also, hx of irregular HR with INR of 1.1
  • Rt foot cooler than Lt, no palp Rt DP or PT
  • Acute onset severe pain started 3hrs ago
  • Embolectomy and anticoagulation
  • Dont forget fasciotomy

15
Clinical Scenario 2
  • New consult for non-healing ulcer, evaluate for
    peripheral arterial bypass.

16
Clinical Scenario 2
  • New consult for non-healing ulcer, evaluate for
    peripheral arterial bypass.
  • Obese 63yo M dialysis w/ DM, HTN
  • Legs down in chair, severely edematous
  • Advised to elevate and compression garments, but
    does not b/c uncomfortable
  • Non-tender medial malleolar ulcer x3 wk
  • B/L DP and PT are palpable

17
Clinical Scenario 3
  • Stat consult to 3A for r/o compartment sx.
  • 39yo F s/p cardiac cath via L radial artery
  • Cath performed for cough, was normal
  • After sheath removed, arm doubled in size
  • Nurses want to know when pt going to OR

18
Clinical Scenario 3
  • Stat consult to 3A for r/o compartment sx.
  • 39yo F s/p cardiac cath via L radial artery
  • Cath performed for sneezing, found normal
  • After sheath removed, arm doubled in size
  • Direct pressure applied, bleeding ceased
  • Palpable distal pulses were appreciated
  • Neurovascular exam intact w/ serial exams
  • Arm elevated to facilitate venous return

19
Bergers Pet Peaves
  • No overnight pre-op IVF unless dehydration
    established or elderly pt AND afternoon case
  • Reglan for N/V unless obstruction, espec DM
  • Zofran ONLY if nausea refractory to Reglan
  • Only attg name on consents except as witness
  • Residents can, however, sign blood consents
  • SCDs for AAAs only (NOT CEAs, bypasses, etc)
  • Vaseline gauze, NEVER iodoform gauze
  • Do NOT elevate extremities after access cases
  • Increases steal symptoms and neuropathy
  • Peri-op edema will resolve, heart level adequate
  • Dextran x24hrs for all CEAs EXCEPT Bergers

20
Vascular Studies
  • Duplex
  • Doppler
  • B-mode doppler
  • ABI/PVR (LEADs)
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