Week 2: Arterial & Venous Insufficiency Wounds

Arterial wound

Wounds that result from a lack of blood flow which deprives the area of oxygen

5% to 10% of all lower extremity ulcerations are because of

AI

AI affects

23% of all Americans age 55+

AI treatment costs

4.37 billion

AI cost reason

surgical debridement

Arterial ulcers are likely to progress without

holistic and meticulous interventions

Arterial flow

artery-->ateriole-->capillary

average arter size

37 Micrometers

Capillary size

1 mm in length and 8-10 micrometers in width

Tunica adventitia

The outer layer of tissue of a blood vessel wall, composed of elastic and fibrous connective tissue.

tunica media

middle layer of artery; made up of smooth muscle fibers and thick layer of elastic connective tissue

tunica media innervation

sympathetic

tunica intima

the innermost layer of a blood vessel

tunica intima contacts

blood cells

Larger arteries closer to heart have

HIGH Pressures

etiology of arterial insufficiency

-Trauma

-Acute Embolism

-Diabetes

-RA

Thromboangitis

-ARTERIOSCLEROSIS

Truma and arterial etiology

damage to an artery

Acute embolism

stops blood flow

Diabetes and AI

Microvascular diseases

Thromboangiitis

inflamed and occluded Blood vessel

Thromboangiitis aka

Buerger's disease

#1 reason for arterial insufficiency

Arteriosclerosis

Arteriosclerosis

hardening of the arteries

Atherosclerosis

condition in which fatty deposits called plaque build up on the inner walls of the arteries

narrowing of arteries

atherosclerosis

atherosclerotic plaque is caused by

High LDL

Presentation of Arterial Insufficiency

-Intermittent claudication

-Ischemic rest pain

-Gangrene

Intermittent Claudication

Activity-specific discomfort due to local ischemia

Pain with Intermittent claudication

ceases after 1-5 mins of rest

Rate of plaque progression exceeds

angiogensis rate

% Of stenosis to feel claudication

50%

Pain from Intermittent claudication occurs

distal to site of occlusion

Iliofemoral artery obstruction pain

buttock, thigh, or calf

Infrapopliteal artery obstruction pain

foot

Ischemic Rest Pain

A more severe symptom of diminished blood flow to the most distal portion of the extremity

Ischemic Rest Pain is more signifacnt than

Intermittent claudication

Ischemic Rest Pain is increased with

elevation

Ischemic Rest Pain is decreased with

rest

increasing tissue O2 demand can fatally upset the balance between O2 supply and tissue demand, causing

ulceration

Repeated bouts of ischemia/reperfusion can lead to

AI ulcer

AI wounds are typically from

trauma

Gangrene occurs in

distal extremities

When oxygen supply does NOT equal demand

cell death occurs

Gangrene

death of tissue associated with loss of blood supply

Gangrene

intermittent claudication

Gangrene presents as

Dead tissue typically dry, dark, cold, and contracted

Dry gangrene

stable and has circulation proximal to it

Wet gangrene

an area of gangrene that becomes secondarily infected by pus-producing bacteria

Dry vs wet gangrene

Dry - ischemia of tissue, looks mummified

its the better of the two

Wet - superimposed infection of dry gangrene (liquefactive necrosis)

Contributing Factors to Arterial Disease

-Hyperlipidemia/ elevated LDL

-Hypertension

-Smoking

-Advanced Age

-trauma

-diabetes

Chronic hypertension causes

thickening and loss of elasticity of the arterial wall

what hypertension is worse

systolic

1 multiple choice option

1 cigarette can do what

decreases wound and O2 saturation by 30% for an hour

Nicotine causes

vasoconstriction

Advanced airway

more susceptible to wounds

mechanical trauma

An injury that results when applied physical force exceeds the tensile strength of the tissue to which the force is applied.

thermal trauma

exposure to excessive heat or cold

chemical trauma

An injury caused by a chemical, such as an acid or an alkali

Diabetes causes

calcification of the arteries

calcification

hardens and narrows vessels

Hyperglycemia impairs

all 3 phases of wound healing

Hyperglycemia decreases

infection fighting ability

A1C

glucose over last 3 months

Normal a1c

less than 5.7%

Diabetic a1c

want it less than 7

ulcers are caused by

underlying pathologies

wounds are caused by

trauma

Pain arterial wounds

Severe unless masked by Neropathy

What increases pain in AI ulcers

elevation

Position of arterial ulcers

distal toes, dorsal foot, areas of trauma

Presentation of arterial ulcers

-Round, regular

-May conform to precipitating trauma

-Pale granulation tissue if present

-Possible necrotic tissue/black eschar

-Minimal or no bleeding/drainage

black eschar

Dead tissue forming a black scab.

gangrene

death of tissue associated with loss of blood supply

periwound and extrinsic tissue of arterial ulcer

-o Thin, shiny, anhydrous skin

-Lack of hair growth

-Thcikened yellow nails

o Pale, dusky, or cyanotic skin

o Dependent Rubor

o Edema unusual, may indicate VI or CHF

periwound

skin around the wound

anhydrous

lack of moisture

why no hair with AI

Lack of blood flow means no nutrients to grow hair

Pulses in Arterial Ulcers

decreased or absent

Temperature and arterial ulcers

cool or decreased

Characteristics of Arterial insufficient wounds

o Begin small and shallow

o Round and regular or conform to trauma

o Any granulation tissue will be pale or grey

o Necrotic tissue desiccated with black eschar

granulation tissue in arterial ulcers

pale or grey

Physical Therapist Tests for Arterial Insufficiency

o Pulses

o Doppler Ultrasound

o Ankle-Brachial Index

o Rubor of Dependency

o Capillary Refill

o Venous Filling Time

Grade 0 pulse

absent, unable to palpate

Grade 1 pulse

diminished

Grade 2 pulse

normal

3 pulse

bounding

Most common pulse occlusion site

The bifurcation of the common femoral artery

blood flow to dorsum of foot

dorsalis pedis

main foot blood supply

posterior tibial artery

Absence of palpable pules should be followed by

more sensitive testing

Just because a pulse is present does not mean

there is no underlying pathology

diabetic pulses

· bounding pulses from arteriosclerosis

femoral pulse site

femoral triangle just inferior to inguinal ligament halfway between pubic tubercle and ASIS

Popliteal artery is continuation

femoral artery

Posterior tibial pulse is between

FDL and FHL

Doppler ultrasound indication

decreased or absent pulses

Doppler ultrasound transducer angle

o parallel to blood flow but angled against the flow

doppler ultrasound assess

o arterial patency

ABI

ankle brachial index