Presentation on theme: "The Vascular Exam Jason Davis, MD. Before the Exam… Obtain history Acute vs. Chronic symptoms Distribution of symptoms Level(s) of extremity pain, etc."— Presentation transcript:
Before the Exam… Obtain history Acute vs. Chronic symptoms Distribution of symptoms Level(s) of extremity pain, etc. Aggravating, Relieving factors Activity/rest, elevation/dependence Co-morbid conditions, vitals
Elements of Vascular Exam Inspect, Palpate, Auscultate Skin pallor/rubor, mottling/ cyanosis, temperature, atrophy, hair distribution Motor function and sensory exam Tissue loss, ulcerations Pulse +/- doppler exam Always compare each w/ contralateral
Vascular Exam tips ■ Doppler signals are NOT Pulses – Palpable pulses include carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tib ■ Bruits vs. Thrills : Audible vs. Palpable ■ Characterization of Pulses – Character (bounding, thready), Rate, Rhythm ■ Characterization of Doppler Signals – Triphasic, Biphasic, Monophasic
Trauma / Hypovolemia ■ If you can palpate: – Radial pulse, then SBP is >70 - 80 – Femoral + Carotid, then SBP >50 - 70 – Carotid only, then SBP >40 - 60 ■ NEVER rely on pulses alone for hypovolemia assessment
Clinical Scenario #1 ■ Routine 5pm ED consult for cellulitis.
Clinical Scenario #1 ■ Routine 5pm ED consult for cellulitis. ■ You see before leaving within your hrs ■ On arrival, 78yo male w/ DM, CAD, +tobacco ■ Also, hx of “irregular HR” with INR of 1.1 ■ Rt foot cooler than Lt, no palp Rt DP or PT ■ Acute onset severe pain started 3hrs ago ■ Embolectomy and anticoagulation ■ Don’t forget fasciotomy
Clinical Scenario #2 ■ New consult for non-healing ulcer, evaluate for peripheral arterial bypass.
Clinical Scenario #2 ■ New consult for non-healing ulcer, evaluate for peripheral arterial bypass. ■ Obese 63yo M dialysis w/ DM, HTN ■ Legs down in chair, severely edematous ■ Advised to elevate and compression garments, but does not b/c uncomfortable ■ Non-tender medial malleolar ulcer x3 wk ■ B/L DP and PT are palpable
Clinical Scenario #3 ■ Stat consult to 3A for r/o compartment sx. ■ 39yo F s/p cardiac cath via L radial artery ■ Cath performed for cough, was normal ■ After sheath removed, arm doubled in size ■ Nurses want to know when pt going to OR
Clinical Scenario #3 ■ Stat consult to 3A for r/o compartment sx. ■ 39yo F s/p cardiac cath via L radial artery ■ Cath performed for sneezing, found normal ■ After sheath removed, arm doubled in size ■ Direct pressure applied, bleeding ceased ■ Palpable distal pulses were appreciated ■ Neurovascular exam intact w/ serial exams ■ Arm elevated to facilitate venous return
Berger’s Pet Peaves ■ No overnight pre-op IVF unless dehydration established or elderly pt AND afternoon case ■ Reglan for N/V unless obstruction, espec DM ■ Zofran ONLY if nausea refractory to Reglan ■ Only attg name on consents except as witness ■ Residents can, however, sign blood consents ■ SCD’s for AAA’s only (NOT CEA’s, bypasses, etc ) ■ Vaseline gauze, NEVER iodoform gauze ■ Do NOT elevate extremities after access cases ■ Increases steal symptoms and neuropathy ■ Peri-op edema will resolve, heart level adequate ■ Dextran x24hrs for all CEA’s EXCEPT Berger’s