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The Vascular Exam Jason Davis, MD. Before the Exam… Obtain history Acute vs. Chronic symptoms Distribution of symptoms Level(s) of extremity pain, etc.

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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:

1 The Vascular Exam Jason Davis, MD

2 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

3 Basic Anatomy to Know

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6 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

7 Elements of Vascular Exam

8 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

9 Trauma / Hypovolemia ■ If you can palpate: – Radial pulse, then SBP is > – Femoral + Carotid, then SBP > – Carotid only, then SBP > ■ NEVER rely on pulses alone for hypovolemia assessment

10 Lower Extremity Ulcers ■ Arterial (PAD) – Distal (often at toes), painful, pale granulation, – Assoc w/ atrophy, hairless/shiny skin, rubor-pallor ■ Venous (VI) – Lower third, medial malleolus, elevation relieves – Assoc w/ edema, larger, irregular, moist base ■ Diabetic – Pressure offloading, footwear, self-checks

11 Common Vascular Problems ■ Peripheral arterial disease – Thrombotic (DM, atherosclerosis) – Embolic (atrial fibrillation, Aneurysms) ■ Venous insufficiency ■ DVT, thrombophlebitis ■ Carotid artery stenosis ■ Compartment Syndrome ■ Trauma

12 Compartment Syndrome ■ Leg compartments – Lower: Anterior, Lateral, Superficial & Deep Posterior – Upper: Anterior (extensor), Medial (adducter), Posterior (sciatic n.) ■ 6 P’s indicating ischemia – Pain – Paresthesias – Palor – Pulselessness – Poikilothermia – Paralysis

13 Clinical Scenario #1 ■ Routine 5pm ED consult for cellulitis.

14 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

15 Clinical Scenario #2 ■ New consult for non-healing ulcer, evaluate for peripheral arterial bypass.

16 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

17 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

18 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

19 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

20 Vascular Studies ■ Duplex ■ Doppler ■ B-mode doppler ■ ABI/PVR (LEADs)


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