ZW

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.