176 Week 8 Day 2

Arterial Issues

• Lack of Distal Pulse:
  • If there's no pulse below a certain point in an arm or leg, it indicates a problem.
  • The area may experience muscle spasms and pain due to ischemia.
• Symptoms:
  • Initially, the area will be extremely pale and cold (like touching marble) due to lack of blood flow (perfusion).
  • The skin may become mottled (splotchy purple).
  • Eventually, the tissue will darken as it dies (necrosis).
• Arterial Embolus:
  • This is a surgical emergency requiring immediate action as “time is tissue.”
  • Necrosis can start quickly, as seen in the example of toes turning necrotic.
• Diagnosis and Treatment:
  • Ultrasound of the popliteal artery can check for clots.
  • Angiography (dye injection) can visualize blood flow and identify clots.
  • Doppler ultrasound can also assess flow.
• Interventions:
  • Thrombectomy (surgical clot removal).
  • Use of clot-busting medications (TPA).
  • Amputation may be necessary if there's bone necrosis to prevent gangrene and sepsis, which can be fatal.
• Long-term Management:
  • Patients with arterial clots will need lifelong anticoagulation to prevent recurrence.

Venous Insufficiency

• Cause:
  • Weakening of vein valves leads to blood backflow and edema in the lower extremities.
  • Veins rely on valves to prevent backflow, which can weaken over time due to prolonged standing or pressure.
  • When valves fail, blood pools, causing swollen feet and ankles.
• Ulcers:
  • Venous ulcers have irregular edges, are deeper than arterial ulcers, and tend to be weepy or wet.
  • Arterial ulcers are shallow, have smooth edges, and are dry.
• Stasis Dermatitis:
  • Blood pooling causes hemoglobin to break down and seep into the skin, leading to discoloration.
  • Unlike necrotic tissue, the skin will blanch when pressed.
• Symptoms and Risk Factors:
  • Pain is often a dull ache or heaviness.
  • Conditions such as DVTs, pregnancy, and obesity can contribute to venous insufficiency.
  • Pregnancy: The uterus compresses vessels, impairing venous return.
  • Obesity: Extra tissue adds pressure, hindering blood flow.
  • Prolonged standing or sitting can worsen symptoms.
• Appearance:
  • Skin may be cool but not as cold as with arterial problems.
  • Feet may turn purple (cyanotic) due to oxygen depletion in pooled blood.
• Management:
  • Elevation of feet helps relieve symptoms because veins carry blood up to the heart.
  • Compression therapy is crucial, but high compression (e.g., 40 mmHg) can be uncomfortable and poorly tolerated.
  • Gradual increase in compression levels may improve patient compliance.
  • Caution: Low compression only for patients with peripheral artery disease (PAD) to avoid collapsing arteries.
• Assessment:
  • Look for varicose veins, spider veins, and edema.
  • Duplex ultrasound (Doppler) is used for diagnosis.
• Stasis Ulcers:
  • Infection risk is high; involve wound care specialists.
  • Hyperbaric oxygen therapy increases oxygen to tissues to promote healing.

Venous Thrombosis

• Phlebitis vs. Thrombosis:
  • Phlebitis: Inflammation of a vein, often from IV irritation.
  • Thrombosis: Clot in a vein, usually with phlebitis.
• Superficial vs. Deep:
  • Superficial phlebitis/thrombosis: Not as concerning; treated with warm compresses, possibly antibiotics if infected.
  • Deep vein thrombosis (DVT): More serious, can occur in upper or lower extremities.
• Virchow's Triad:
  • The perfect storm for a clot.
    • Stasis: Blood isn't flowing properly, may by caused by chronic PVD.
    • Vessel Wall Damage: Atherosclerosis or tears.
    • Hypercoagulability: Dehydration, medications, hormones.
• DVT
  • Deep vein thrombus.
  • Superficial phlebitis we're gonna take care of it, but we're not gonna freak out about the superficial.
• Risk factors
  • Long trips.
  • Long flights.
  • Recent hospitalization or surgeries.
  • Extensive bed rest.
  • Cancer treatments.
  • Oral contraception.
  • Hormone replacement therapy.
• Symptoms:
  • 50% of the time, no symptoms at all.
  • Swelling.
  • Warmth.
  • Redness.
  • Pain.
• Diagnosis:
  • Duplex ultrasound to look for clots.
  • D-dimer test: If negative, DVT is unlikely; if positive, further investigation is needed.
• Goal of Treatment
  • To prevent clot from getting bigger.
  • Want to keep the clot from breaking off.
• Treatments
  • Anticoagulation.
  • Inferior vena cava filter: Traps clots before they reach the lungs.
• Pulmonary Embolism (PE)
  • A blood clot that has broken free and traveled to the lungs.
• PE Explanation (Illustration)
  • DVTs can obstruct blood flow.
  • A piece of the clot may break free and travel through the bloodstream.
  • The clot passes through the heart and into the pulmonary arteries.
  • It can lodge in smaller lung vessels, causing a pulmonary embolism.
  • PEs can be fatal if not promptly treated.
  • Common sign of a PE is shortness of breath.
  • Other symptoms may include:
    • Pain in the chest.
    • Fast heart rate.
    • Fast breathing.
• Diagnosis:
  • Doppler ultrasound.
  • CT pulmonary angiography (preferred).
  • Ventilation-perfusion scan (if CT is not possible because patient can't lie flat).
• Assessments:
  • ABGs: to check gas exchange.
  • Electrocardiogram: To access the heart.
• Treatments:
  • IV fluids.
  • Embolectomy: surgical removal of the clot.
  • Ecos: catheter that breaks up the clot.
• Symptoms:
  • Patient will look really bad.
  • Be tachypneic, hypoxic, dyspneic, tachycardic.
  • Hemoptysis.
  • ABGs will be abnormal.
• Causes:
  • Fractures: From bone marrow entering circulation.
  • Air embolus: During dialysis or IV issues.
  • Amniotic fluid embolus: During pregnancy/delivery complications.
  • Bacterial: Endocarditis.
• Symptoms:
  • Sudden death.