Peripheral vascular examination

How do start the examination- general?

1. Wash your hands- PPE

2. introduce yourself

3. Check name and date of birth

4. Gain consent

5. Explain the process

6. Offer a chaperone

7. Expose the patient appropriately

8. Position appropriately

9. Check for pain

What occurs after the general/ first part of the examination?

General inspection

What is a general inspection?

1. Observe the patient's general condition

2. Observe around the bed

What can be observed around a patient's bed?

Medical equipment: note any dressings and limb prosthesis.

Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.

Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.

Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.

What can be observed in the patient's general condition?

Look for stigmata of coronary vascular disease such as:

• Tar staining- caused by smoking, a significant risk factor for cardiovascular disease (e.g. PVD, coronary artery disease, hypertension).

• Scars from cardiac/ vascular surgery

• Amputated limbs or digits

• Xanthelasma- eyes

• Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.

• Areas of necrosis or gangrene

• Ulcers

• Livedo reticularis

• Hair loss

• Micro-emboli

How do you observe the body?

You start from the hands then you go up to the head. After that you move down.

What + how do you examine in the hands/nails?

1. Peripheral cyanosis- bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).

2. Perfusion (CRT)- press down on the nail for 5s then they should return back to their original colour (red) within 3s max

3. Clubbing- look at the pic

4. Look at the skin for thinning/ bruising

5. Peripheral pallor: a pale colour of the skin that can suggest poor perfusion (e.g. PVD).

6. Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.

What does a higher CRT (capillary refill time) indicate?

A CRT that is greater than two seconds suggests poor peripheral perfusion.

What should you check before doing the CRT?

Prior to assessing CRT, check that the patient does not currently have pain in their fingers.

What causes a radio-radial delay?

Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection

What do you examine after hands?

arms

What + how do you examine the arms?

1. Radial pulse (on both arms together to compare)- rhythm, rate, character (weak/bounding), R-R delay.

2. Counts RR when feeling peripheral pulse

3. Ask for BP (tell the examiner you would do BP, they would tell you to move on or give you a result)

4. Temperature of both arms/hands

How to examine the temperature if the arms?

Place the dorsal aspect of your hand onto the patient’s upper limbs to assess temperature.

What is seen in a healthy individual's arm temperature?

In healthy individuals, the upper limbs should be symmetrically warm, suggesting adequate perfusion.

What does a cool and pale temperature of the arms indicate?

A cool and pale limb is indicative of poor arterial perfusion.

What do you examine after the arms?

Head + neck

How do you calculate the brachial pulse?

Palpate the brachial pulse in each arm, assessing volume and character:

• Support the patient’s right forearm with your left hand.

• Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.

• With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.

• Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.

What does an abnormal blood pressure indicate?

Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection.

A more than 20 mmHg difference in BP between arms is abnormal and is associated with aortic dissection.

What do you examine after the arms?

Head + neck

What do you do before palpating the carotid pulse + why?

Auscultate the carotid artery to rule out the presence of a bruit.

The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.

How do you palpate the carotid pulse?

1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).

2. Gently place your fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.

3. Assess the character (e.g. slow-rising, thready) and volume of the pulse.

What do you inspect in the abdomen?

Inspect the abdomen looking for any obvious pulsation. The abdominal aorta can be located in the midline of the epigastrium.

How do you palpate the abdominal aorta?

1. Using both hands perform deep palpation just superior to the umbilicus in the midline.

2. Note the movement of your fingers:

What is a an abnormal sign when palpating the abdominal aorta?

In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).
This is a crude clinical test and further investigations would be required before a diagnosis of an abdominal aortic aneurysm was made.

Where do you auscultate for the aorta and renal arteries?

Aorta- auscultate 1-2 cm superior to the umbilicus

Renal arteries- auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side.

What are aortic bruits associated with?

abdominal aortic aneurysm

What are renal bruits associated with?

renal artery stenosis.

What do you inspect in the lower limbs?

• Peripheral cyanosis: bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).

• Peripheral pallor: a pale colour of the skin that can suggest poor perfusion.

• Ischaemic rubour: a dusky-red discolouration of the leg that typically develops when the limb is dependent. Ischaemic rubour occurs due to the loss of capillary tone associated with PVD.

• Venous ulcers: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.

• Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).

• Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue. Missing limbs, toes, fingers: due to amputation secondary to critical ischaemia.

• Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.

• Hair loss: associated with PVD due to chronic impairment of tissue perfusion.

• Muscle wasting: associated with chronic peripheral vascular disease.

• Xanthomata: raised yellow cholesterol-rich deposits that may be present over the knee or ankle. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.

• Paralysis: critical limb ischaemia can cause weakness and paralysis of a limb. To perform a quick gross motor assessment, ask the patient to wiggle their toes.

What do you examine in the lower limb?

1. Temperature

2. CRT

3. Pulses

4. sensation

5. Buerger’s test

How do you examine the femoral pulse?

Palpate the femoral pulse:

The femoral pulse can be palpated at the mid-inguinal point, which is located halfway between the anterior superior iliac spine and the pubic symphysis.
Check that the pulse is present and assess the pulse volume.
Assess for radio-femoral delay:

Palpate the femoral pulse and radial pulse simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the pulses are out of sync, this indicates radio-femoral delay.
Auscultate over the femoral pulse to screen for bruits:

Bruits in this region suggest either femoral or iliac stenosis.

How do you examine the popliteal pulse?

Palpate the popliteal pulse:

The popliteal pulse can be palpated in the inferior region of the popliteal fossa.
With the patient supine, ask them to relax their legs and place your thumbs on the tibial tuberosity.
Passively flex the patient’s knee to 30º as you curl your fingers into the popliteal fossa. This should allow you to feel the pulse, as you compress the popliteal artery against the tibia.
This pulse is often difficult to palpate, so don’t pretend you can feel it if you can’t. The popliteal artery is one of the deepest structures within the fossa, so the examiner will understand if you are unable to locate the artery.

How do you examine the Posterior tibial pulse?

Palpate the posterior tibial pulse:

The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

How do you examine the dorsalis pedis pulse?

Palpate the dorsalis pedis pulse:

The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones.
Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Why do you examine sensation?

Slowly progressive peripheral neuropathy is common in patients with significant peripheral vascular disease. This results in a glove and stocking distribution of sensory loss. Acute critical limb ischaemia causes rapid onset parathesia in the affected limb.

What is the Buerger’s test?

Buerger’s test is used to assess the adequacy of the arterial supply to the leg.

To perform Buerger’s test:

1. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.

2. Observe the colour of the limbs:

The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle. In a healthy individual, the entire leg should remain pink, even at an angle of 90º. A Buerger’s angle of less than 20º indicates severe limb ischaemia. 3. Sit the patient up and ask them to hang their legs down over the side of the bed:

Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb. The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).