Week 6 - Arterial Insufficiency

pathophysiology of arterial wounds

insufficient blood flow due to narrowed or blocked arteries --> tissue ischemia and necrosis (usually in distal extremities)

t/f: arterial wounds often present with dry, necrotic tissue and poor healing due to lack of oxygen and nutrients

true

risk factors for arterial wounds (8)

- Diabetes (sugar = bumper cars on arterial walls)

- Smoking (raises BP, causes vasoconstriction, delays tissue healing, deteriorates the tissue)

- Advanced age

- Personal hx of a heart attack, stroke, or TIA; family hx of PAD

- HTN

- Overweight

- High cholesterol

- Physically inactive

Differentiate b/w arterial and neurogenic claudication.

Arterial:

- gradual onset

- described as pulsating, cold to the touch, cramping, aching, N/T, PAINFUL (usually in the calves)

- aggravated by physical activity or exercise

- eased by rest

- they need to hang leg off bed to make it feel better

Neurogenic:

- gradual onset

- described as vague cramping, aching, burning (usually in the LE); "Grocery cart sign"

- aggravated by lumbar extension

- eased by lumbar flexion

Where are arterial insufficiency wounds typically located?

Below the ankle (foot, heel, MT heads, tips of toes, "bunion" areas, possible superior to lateral malleolus or anterior lower leg, dorsal aspect of hands or fingers)

Can you describe the common presentation of an arterial wound?

shallow, 'punched out,' regularly shaped/round

do arterial wounds commonly have drainage?

no - minimal to none, dry and hard wound bed

what is the tissue usually like for arterial wounds

black/brown eschar, pale granulation tissue, mixed

Can you differentiate between wet and dry gangrene? How should we best proceed with the plan of care?

Dry = mummification, no drainage, little/no odor; clear demarcation --> protect and monitor (only wound that we want to keep dry!)

Wet = drainage, odor, edema, erythema; less clear demarcation --> urgent referral

What is wet gangrene? What should we do if wet gangrene is noted?

Drainage, odor, edema, erythema @ the arterial wound site

Less clear demarcation, URGENT REFERRAL (high risk of infection)

When should a vascular assessment be performed?

A vascular assessment should be performed to examine (suspected or confirmed) arterial wounds, arterial insufficiency, PAD, etc. (i.e., vascular conditions)

components of a vascular assessment

capillary refill test, palpation of pulses, skin inspection, doppler, bedside ABI

What should encompass a skin assessment/inspection of arterial wounds? and what would it look like for an arterial wound

Skin quality (shiny, thin, cracked), hair (hairless), edema (minimal -- unless a mixed etiology), skin color (pale, deep red rubor), toenails (thick, flakey)

What is critical limb ischemia (aka chronic limb-threatening ischemia or CLTI)?

Reduction in distal tissue perfusion BELOW the resting metabolic requirement (usually associated w/ atherosclerosis in those w/ diabetes) --> PAD + rest pain, gangrene, or ulceration of the LE

t/f: critical limb ischemia requires revascularization to ensure that the max. amount of arterial perfusion is present to support wound healin

true

What are the critical phases of ischema?

1 = collateral circulation is insufficient for the metabolic needs of the affected extremity (greater risk of infection and poor healing)

2 = activity or exercise starts to cause relative ischemia and pain (intermittent claudication)

3 = patient may experience rest pain, gangrene, or nonhealing wounds

What is the difference between macrocirculation and microcirculation?

Macrocirculation = large arteries >0.5 mm

Microcirculation = smaller capillaries and arterioles <0.5 mm

*NOTE: atherosclerosis tends to affect the LARGE vessels while reduced capillary flow (also called small vessel disease) is observed most frequently as a result of diabetes*

How do you interpret the results of a bedside ABI?

Poorly compressible >1.2

Normal 1.0 - 1.2

Mild obstruction 0.8-1.0

Mod obstruction 0.5-0.79

Severe obstruction <0.5

Distinguish between modifiable and non-modifiable risk factors of atherosclerosis (and subsequently arterial wounds).

Modifiable: smoking, HTN, HLD, obesity

Non-modifiable: age, family history, air pollution (unless you move to another city I suppose), diabetes (however, your blood sugar itself is modifiable)

What is "rest pain"?

Patient elevates their legs --> they CANNOT tolerate it --> may dangle their legs to get their blood flow where it needs to go

How can we differentiate between a healable and unhealable arterial ulcer?

Arterial insufficiency ulcers are considered "unhealable" until proven otherwise!!

Unhealable ulcers: keep dry, no moist wound promotion

Healable ulcers: ABI >0.5, consult vascular physician

List wound care principles.

1. "Unhealable" until proven otherwise

2. Wet gangrene = vascular ASAP, dry gangrene = protect, offload, monitor

3. Monitor for infection

4. ROM and exercise programs as appropriate

List wound care precautions for a HEALABLE ulcer (ABI >0.5)

consult vascular physician

1. Expect slower progress

2. Moist wound environment w/ caution

3. Avoid adhesives

4. PT role: ID, refer, protect,monitor, educate (wound care, exercise, treatment after revascularization or amputation)

When is debridement contraindicated?

Poor blood supply = sharp debridement is typically contraindicated UNTIL given the "A-okay" by the vascular surgeon

No debridement if ABI <0.8 or dry stable eschar unless okayed by physician

List components of post-revascularization care.

1. Verify and frequently monitor vascular stats

2. Shift goal toward healing -- moist wound environment and debridement

3. Amputation care: wrapping, shaping, prosthetics -- ROM, strengthening, mobility, balance, offloading