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CDR Doug E. Henry, PT, CWS® Federal Medical Center - Butner, NC.

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Presentation on theme: "CDR Doug E. Henry, PT, CWS® Federal Medical Center - Butner, NC."— Presentation transcript:

1 CDR Doug E. Henry, PT, CWS® Federal Medical Center - Butner, NC

2  Outline the BOP Guidelines for evaluating vascular disease  Identify the clinical signs of peripheral arterial disease/PAD  Summarize the significance of the ABI examination in relationship to evaluation of PAD  Summarize the strengths & limitations of ABI examination  Describe or interpret how current literature impacts clinical findings of the ABI examination  Outline which class of compression stockings are indicated or contraindicated for pnts


4  The comparison of blood pressures in the arms (brachial) and lower extremities both (posterior-tibial) and (dorsalis pedis), using an appropriately sized blood pressure cuff and a Doppler. The highest systolic reading of the DP or PT pulse, indicated by the first audible Korotkoff sound, is divided by the highest systolic brachial reading. This gives the clinical ratio for interpretation. ABI or ABPI Procedure

5 Tissue Ischemia Poor Vascularity Instability of metabolites – Decreased H&H, Dehydration, poor glucose control… Nutrition – Low Albumin for Healing Demand Heavy Bacterial Bio-burden Infection Other

6 Atherosclerosis  Tobacco use  Metabolic Syndrome: DM, HTN, Dyslipidemia,Obesity  CAD  Thromboangitis obliterans  Vasculitis  Renal Disease  Raynaud’s Disease  Sickle Cell Disease  Other…

7 ACC/AHA 2005 Guidelines for the Management of Patients with Peripheral Arterial Disease, Journal of American College of Cardiology, vol 47, 2006 AgeIndividuals at Risk for Lower Extremity PAD <50DM and one other risk factor (smoking, dislipidemia, hypertension) 50-69History of smoking or DM 70All patients older AnyLeg symptoms with exertion (suggestive of claudication) or ischemic rest pain AnyAbnormal LE pulse examination AnyKnown atherosclerotic coronary, carotid, or renal artery disease

8  Clinical presentation: Claudication, atrophy, reduction of mobility, integumentary lesions, and delayed or unexplained slow healing wounds.  Local presentation: discoloration, bruising, numbness, weakness, decreased pulses, atrophic appearance.

9  Diminished blood flow resulting in tissue ischemia, ↓ O2 levels, ↓ neutrophil activity, ↓ inflammatory response = ↑ rates of infection…  ↑ NON-healing ulcerations → necrosis → gangrene, amputation… Pathophysiology

10 BOP Diabetes Management 2012 Wound Care March 2014

11  Jeffrey Allen, MD  Matt Hardin, Dermatologist  CDR Kevin Elker, RN, CWOCN  CAPT Matt Taylor (ret), PT, DPT, OCS, CWS  Pam Baker, RN, CWOCN  Patina Walker-Geer, NP  CDR Christine Fallon, NP, WCC  LCDR Sherrie Wheeler, RN  CDR Cubie Beasley, RN  ….


13  Skin Temperature  Capillary Refill  Palpation of LE pulses DP & PT  Elevation Pallor  Dependent Rubor  Atrophic foot

14  Pain 1. Intermittent Claudication 2. Nocturnal pain 3. Rest pain Normal Vessel Claudication 50% Nocturnal pain Rest pain 90%

15 Ruthorford, BR et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. Journal of Vascular Surgery. Sept 1997; 26. 517-38.  Patients report pain with activity.  Calf or leg/s feel heavy or cramping pain when they walk a specific distance each time.  Relieved with about 10 minutes of rest.  Occurs when the involved vessel is approximately 50% occluded.  Occurs at night when the patient is in bed  Relieved by placing the legs in a dependent position to increase blood flow, often over the edge of the bed.  Occurs in the absence of activity with legs in a dependent position  Indicates advanced occlusive disease, typically greater than 90% of the affected vessel/s

16 ABI ValueDisease severity >0.90No disease 0.69-0.90Mild to moderate intermittent claudication 0.40-0.60Severe intermittent claudication 0.25-0.40Rest pain and tissue loss Aronow WS. Management of peripheral arterial disease. Cardiology Review. 2005;13(2):61-68.

17  Intact: cold, dry, flaking, chaffing, shiny skin, bluish, thick toenails, non-palpable pulse, chronic loss of autonomic and/or protective sensation  Open: eschar, denuded/dry wound bed. Arterial Ulcerations   If cellulitis, abscess, gangrene, or deep ulceration is present, consider immediate referral for treatment and amputation prevention

18  With the patient in the supine position, elevate the affected leg approximately 60 degrees. Note the color of the soles of the foot while elevated  Note the total = T/sec to pallor  The presence of a purplish-red discoloration in one or both legs is caused by the retention of de-oxygenated blood in the dilated skin capillaries of a patient with arterial disease. To differentiate from cellulitis or other mechanisms, have the patient lie in a supine position and elevate the leg approximately 60 degrees. If the discoloration fades, the most likely mechanism is dependent rubor

19 Ermer-Seltun J. Lower Extremity Assessment, Acute and Chronic Wounds. 2012, pg. 173. Pallor developing within…INDICATES 25 secondsSevere arterial disease 25-40 secondsModerate arterial disease 40-60 secondsMild arterial disease 60 secondsNo arterial disease Interpretation per BOP Wound Care CPG


21 EBM

22  Evaluation of PAD  Assessment of LE circulation pre-surgically  Assessment of LE circulation s/p re- vascularization procedures  Risk for cardiovascular events including all causes leading to mortality  Simple, quick & non-invasive diagnosis  Cost-Effective!

23 Lower ankle/brachial index, as calculated by averaging the dorsalis pedis & posterior tibial arterial pressure, & association with leg functioning in peripheral arterial disease McDermott et al, Journal of Vascular Surgery, Dec 2000 n= 244 men & women age 55+ with & w/o PAD Outcome measures = walking velocity & endurance measured with 6min/walk test Reviewed 3 different methods of calculating ABI to determine the best testing method

24  PAD defined as ABI less than < 0.90  Method 1: higher LE arterial pressure - 47%  Method 2: lower LE arterial pressure - 59%  Method 3: average of dorsalis pedis & posterior tibial pulses used to calculate ABI 52%  Results: Method #2 was most closely associated with correctly predicting PAD but Method #3 predicted leg function using the outcome measures in regression analysis

25 Khan et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews. 2008, 4, 101-106 AuthorSpecificitySensitivityConditions Schroeder et al.99%68%Highest AP 93%89%Lowest AP Niazi et al.83%69%Highest AP 64%84%Lowest AP Lijemer96%79%Highest AP Stoffers et al82%79%Highest AP

26 For a 60 year old person with a positive reading less than 0.80 [0.90] what is the probability of mortality in this patient? Relationship of High and Low Ankle Brachial Index to All-Cause and Cardiovascular Disease Mortality: Resnick et al, Circulation 2004

27  n= 4549, age 45-74, ethnicity native, outcome = mortality, retrospective cohort, level 2B  Both abnormally low (4.9%) and high (9.2%) ABI results are linked to cardiovascular events  All cardiac events were associated including: CVA, TIA, MI…  PAD determined by ABI <0.90


29 AHA Measurement and Interpretation of ABI – Aboyans et al 2012 ABI RatioINDICATION >/= 1.30Indicates non-compressible vessels >250mmHg. This finding is common in diabetic patients, due to increased rates of arteriosclerosis. Further diagnostic testing may be needed to evaluate whether blood flow is adequate for healing 1.0 to 1.29 Normal ratio 0.8 to 0.99 Blood flow should be adequate for healing. < 0.8Patient may need to be referred for further diagnostic testing to evaluate whether blood flow is adequate for healing

30 IDSA Guidelines for Diabetic Foot Infections - Lipsky et al 2012 ABI RatioINDICATION >/= 1.30Poorly Compressible vessels, Arterial calcification 0.9 to 1.30Normal ratio 0.60 to 0.89Mild arterial obstruction 0.40 to 0.59Moderate obstruction < 0.40Severe obstruction

31  The ABI is one screening tool  Elevated BP → erroneous results  Chronic Long Term Diabetes often N-C  Perform Toe Brachial Index (TBI) in patients with non-compressible vessels  Refer to vascular for advanced testing  Non-invasive: LEAD studies/segmental limb pressure, doppler wave, pulse volume recorders, TcPO2, MRA, duplex angiography  Invasive: Arteriogram, CTA

32 Assessment tool for arterial pathology- Compression Therapy VenousArterial Comfort w/ compressionSubjective pain &/or discomfort Normally good skin turgor +Atrophic signs at foot Pulses normal or obscurePulse weak or absent

33 ClassmmHgIndications 120-30mmHg (light)Varicosities 230-40mmHg (medium)Venous Insufficiency, +/- ulcer 340-50 mmHg (strong)Treatment of refractory ulcer 450-60 mmHg (high)Lymphedema Byrant, RA, Nix, DP: Acute & Chronic Wounds, Current Management Concepts, 3 rd Ed, Mosby Elsevier 2007, St. Louis, MO. Pp 299-306.

34 TypeAvailableContra-indicatedIndications TED Hose (8-12 mmHg pressure) SupplyAmbulatory Patients! Post-op DVT prevention, bed- bound pnts Therapeutic Stockings (20- 30mmHg) PTSevere Arterial disease (PAD), cellulitis, CHF (caution) Dependent edema control, varicose veins, lymph prevention (post-mastectomy) Therapeutic Stockings 30-40mmHg PTmod-severe PAD, cellulitis, CHF Venous insufficiency, venous stasis, venous ulcers CustomPTsame as aboveLymphedema pts, morbidly obese, anatomical variety

35  Advantages: Provide graded compression, enhance circulation for wound healing, pain relief, and prevention of DVT, variety of styles for ease of application.  Disadvantages: Can be difficult to apply, require compliance, cleaning (cannot be dried in dryer)

36  Applied before getting out of bed in the morning, removed at night or bathing ONLY (TED hose worn in bed by the non-ambulatory for prevention)  Wash in washing machine, hang dry  Should last 8-12 months  D/C if develop chest pains or skin irritation, consider less compression if skin tears at dorsal crease in elderly  Lower compression options=tubi-grip D, E & F

37  The evaluation of arterial disease is a critical step for wound healing at the LE  Treatment delays increase probability of failure  PAD pnts have higher cardiac risks, mortality and amputation risks  Limb salvage in the diabetic population is greatly improved with assertive mgmt!

38  PMH  Subjective Report  Clinical Examination  Clinical Tests for Arterial Disease  ABI (Sensitivity & Specificity)  Referral: Vascular Medicine


40 PMH Subject Report Clinical Findings ABI Referral D2HENRY@BOP.GOV

41 Rothwell PM. External validity of randomised controlled trials: "to whom do the results of this trial apply?" Lancet 2005; 365(9453):82-93External validity of randomised controlled trials: "to whom do the results of this trial apply?" Montori VM, Jaeschke R, Schunemann HJ, Bhandari M, Brozek JL, Devereaux PJ et al. Users' guide to detecting misleading claims in clinical research reports BMJ 2004; 329(7474):1093-1096Users' guide to detecting misleading claims in clinical research reports Amsler et al. In search of optimal compression therapy for venous leg ulcers: A meta-analysis of studies comparing divers bandages with specifically designed stockings. J Vasc Surg 2009;50:668-74. Straus, Sharon, Richardson W. Scott, Glasziou, Paul, Haynes R. Brian. Evidence- Based Medicine. How to Practice and Teach EBM. 2005 3 rd Edition, Elsevier Churchill Livingstone. Byrant, RA, Nix, DP: Acute & Chronic Wounds, Current Management Concepts, 3 rd Ed, Mosby Elsevier 2007, St. Louis, MO. Pp 299-306. Guyatt, Gordon, Rennie, Drummond. Users’ Guides to the Medical Literature. Essentials of Evidence-Based Clinical Practice. 2005 4 TH Edition, JAMA & Archives Journals, AMA.

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